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DMERC Region D EDI Manual Complete April 2003

1. Edit Edit Description Element Edit Explanation Number Segment ID 11175 SPINAL MANIP CR201 You have included a spinal manipulation service count for TREAT NOT this line This information is invalid USED IN X12 VERS This edit indicates an invalid format and should be resolved by contacting your software vendor This information is not used for DMERC 11176 SPINL MANIP CR202 You have included a spinal manipulation service quantity for TREAT TOT this line This information is invalid NOT USED IN X12 VERS This edit indicates an invalid format and should be resolved by contacting your software vendor This information is not used for DMERC 11177 SUBLUX LVL CR203 You have included a spinal manipulation subluxation level CODE 1 NOT code for this line This information is invalid USED IN X12 VERS This edit indicates an invalid format and should be resolved by contacting your software vendor This information is not used for DMERC 11178 SUBLUX LVL CR204 You have included a spinal manipulation subluxation level CODE 2 NOT code for this line This information is invalid USED IN X12 VERS This edit indicates an invalid format and should be resolved by contacting your software vendor This information is not used for DMERC 11179 CHIRO TREAT CR205 You have included a spinal manipulation unit code for this TIME QUAL line This information is invalid NOT USED IN X12 VERS This edit indicates an invalid format and should be reso
2. Edit Edit Description Element Edit Explanation Number Segment ID 11064 BILLING PROV N3 The segment providing the billing provider address for this ADDRESS transaction is missing When sending billing provider SEGMENT information you must include address information MISSING 11065 PAY TO PROV N3 The segment providing the pay to provider address for this ADDR transaction is missing When sending pay to provider SEGMENT information you must include address information MISSING This information is not used for DMERC 11066 CANNOT SEND NM1 The segment providing the payer name information for this gt 1 PAYER transaction exceeds maximum use When this information is NAME reported only 1 occurrence per transaction may be used SEGMENT 11067 RESP PARTY N3 The segment providing the responsibility party address for STREET this line exceeds maximum use When this information is ADDRESS SEG reported only 1 occurrence per transaction may be used MISSING 11068 RESP PARTY N4 Responsibility party city state zip segment is missing If you C S Z SEG have indicated the subscriber has a rep payee this is a MISSING required segment 11069 PATIENT NM1 The segment providing the patient s when other than the NAME subscriber name information for this transaction exceeds SEGMENT maximum use When this information is reported only 1 MISSING occurrence per claim may be used This information is not used for DMERC 11070 PT STREET N3 The
3. Region D DMERC EDI Manual Revised April 2003 Front End Edits Medicare Page 31 Edit Number EDIT DESCRIPTION Element ID Edit Explanation 20185 ORDERING PROV ID NM108 The qualifier used to indicate the ordering provider s QUAL INVALID primary identification number for this line is invalid Valid values 24 Employer s identification number 34 Social Security Number XX National Provider Identifier 20186 REF PROV ID QUAL NM108 The qualifier used to indicate the referring provider s INVALID primary identification number for this line is invalid Valid values 24 Employer s identification number 34 Social Security Number XX National Provider Identifier This information is not used for DMERC 20187 SUPPLIER REF The loop containing the secondary identification CREDIT DEBIT number for the credit debit card billing information was INFOR NOT USED sent with this transaction This information cannot be sent to Medicare 20188 CREDIT DEBIT NM1 The loop containing the credit debit cardholder NAME INFO NOT information was sent with this claim This information is USED not to be sent to Medicare 20189 SUBSCRIBER AMT The segment containing the amount to be credited to CREDIT DEBIT INFO the credit debit card account was submitted with this NOT USED claim This information cannot be sent to Medicare This information is not used for DMERC 20190 SPEC PROG IND CLM12 The code indicating the
4. Edit Edit Description Element Edit Explanation Number Segment ID 10169 PAT ENTITY NM102 The qualifier identifying the patient when other than TYPE QUAL subscriber type is invalid for this claim INVALID Valid Value 1 Person This information is not used for DMERC 10170 PAT LAST NM103 The last name is missing for this claim If you have specified NAME the patient when other than the subscriber type to be a MISSING person this element must contain the last name of that person This information is not used for DMERC 10171 PAT FIRST NM104 The first name of the patient when other than the NAME subscriber is missing for this claim If you have specified the MISSING patient when other than the subscriber type to be a person this element must contain the first name of that person This information is not used for DMERC 10172 PAT ID NM108 The qualifier identifying the patient when other than the NUMBER subscriber identification number for this claim is invalid QUAL INVALID Valid Values MI Member Identification Number ZZ Mutually Defined This information is not used for DMERC 10173 PAT ADD N2 The segment providing additional patient s when other than NAME subscriber name information for this claim exceeds SEGMENT EXC maximum use When this information is reported only 1 MAX USE occurrence per transaction may be used This information is not used for DMERC 10174 PAT ADR N3 The segment providing the pa
5. Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 187 Edit Edit Description Element Edit Explanation Number Segment ID 11080 OTHER PAYER REF The segment containing the other payer prior authorization PRIOR AUTH or referral number is missing for this line NUMBER MISSING This information is not used for DMERC 11081 LINE DTP The line adjudication date segment is missing for this line ADJUDICATION DATE MISSING This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 11082 CANNOT SEND NM1 The segment providing the submitter name information for gt 1 SUBMITTER the submitter of this transaction exceeds maximum use NAME When this information is reported only 1 occurrence per SEGMENT transaction may be used 11083 INVALID DATE DTPO1 The qualifier used to indicate the date being reported at the QUALIFIER ON claim level is invalid CLAIM 11084 INVALID DATE DTPO1 The qualifier used to indicate the date being reported at the QUALIFIER ON line level is invalid LINE 11085 SVC FACILITY CLMO0O5 1 The place of service reported at the claim level requires that ADDRESS a service facility address be included with this claim MISSING 11086 CONTRACT CN103 Contract percent cannot be greater than 6 positions EXCEEDS MAXIMUM This information is not used f
6. Front End Edits Page 17 Edit Edit Description Element Edit Explanation Number Segment ID 10080 PAYTO ENTITY NM102 The qualifier identifying the pay to provider type is invalid for TYPE QUAL this transaction INVALID Valid Values 1 Person 2 Non Person Entity This information is not used for DMERC 10081 PAYTO NM103 The last name or company name is missing for this LAST ORG transaction If you have specified the pay to provider type to NAME be a person this element must contain the last name of that MISSING person If the pay to provider was identified as a non person entity this element must contain the company name This information is not used for DMERC 10082 PAYTO FIRST NM104 The first name of the pay to provider is missing for this NAME transaction If you have specified the pay to provider type to MISSING be a person this element must contain the first name of that person If the pay to provider was identified as a non person entity this element is not used This information is not used for DMERC 10083 PAYTO ID NM108 The qualifier identifying the pay to provider identification NUMBER number for this transaction is invalid QUAL INVALID Valid Values 24 Employers Identification Number 34 Social Security Number XX Health Care Financing Administration National Provider Identifier This information is not used for DMERC 10084 PAYTO PROV N2 The segment providing additional name infor
7. 40087 NDC SERVICE LINO3 The National Drug Code NDC submitted is not valid based DATES NOT on the service date entered Please verify the NDC was WITHIN RANGE entered correctly and is effective for the service date entered www cignamedicare com edi Revised April 2003 Chapter Ten Contact Information NEW Supplier Resource Sheet The Supplier Resource Sheet contains key resources for common inquiries Refer to the resource sheet before contacting a customer service agent who is responsible for addressing complex inquiries that can not be handled through other means identified on this document Use the Supplier Resource Sheet as your first point of reference For your convenience the resource sheet is included in this chapter and is also accessible via the CIGNA Medicare Web site at www cignamedicare com If after referring to the resource sheet you are still unable to obtain the necessary information please see additional Region D DMERC contact information below Additional Region D DMERC Contacts NEW Call the Interactive Voice Response IVR Unit at 877 320 0390 toll free for questions regarding e Status of a claim electronic or paper e Fee schedules e Outstanding checks e Ordering payment reports e Annual deductible e Ordering publications e Eligibility status e Appeal rights e Legislation issues NEW To speak with a Customer Service Agent located in Nashville Tennessee call 866 243 7
8. Appendix e DMERC Region D Companion Document Trading Partner Agreement updated 05 22 02 www cignamedicare com edi Revised April 2003 d HealthCare x CENTERS for MEDICARE amp MEDICAID SERVICES Medicare Administration DMERC Region D Companion Document Trading Partner Agreement The Health Insurance Portability and Accountability Act HIPAA requires that Medicare and all other health insurance payers in the United States comply with the EDI standards for health care as established by the Secretary of Health and Human Services The ANSI X12N 837 implementation guides have been established as the standards of compliance for claim transactions The implementation guides for each transaction are available electronically at www wpc edi com The following information is intended to serve only as a companion document to the HIPAA ANSI X12N 837 implementation guides The use of this document is solely for the purpose of clarification The information describes specific requirements to be used for processing data in the ViPS Medicare processing system of CIGNA Healthcare Medicare Administration CIGNA Medicare Contractor number 05655 The information in this document is subject to change Changes will be communicated in the standard DMERC Dialogue and EDI Edge quarterly news bulletins and on CIGNA Medicare s Web site www cignamedicare com This companion document supplements but does not contradict any requirements in
9. Edit Number EDIT DESCRIPTION ElementID Edit Explanation 20099 SUBSCRIBER FIRST NM104 The other insured s first name was entered in an invalid NAME INVALID format Verify the first position of the insured s first name does not contain a space and the name only contains alpha characters This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare This information is used for Medigap secondary to Medicare claims and should not be submitted unless there is an approved Medigap policy held by this subscriber www cignamedicare com edi Revised April 2003 Page 16 Chapter Eight Edit Number EDIT DESCRIPTION Element ID Edit Explanation 20100 SUBSCRIBER MIDDLE NAME INVALID NM105 The other insured s middle name was entered in an invalid format Verify only alpha characters are present This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare This information is used for Medigap secondary to Medicare claims and should not be submitted unless there is an approved Medigap policy held by this subscriber 20101 IDENTIFICATION CODE QUALIFIER INVALID NM108 The qualifier identifying the other insured s identification number for this claim is inval
10. Edit Explanation 10300 RLINQ CARE DT FUTURE DT DTPO3 The date assumed relinquished care entered is invalid for this claim When entered this information must not be greater than today s date This information is not used for DMERC 10301 ATTACHMENT TYPE QUAL INVALID PWK01 The qualifier specifying the type of attachment for this claim is invalid Valid Values 77 Support data for verification AS Admission summary B2 Prescription B3 Physician order B4 Referral form CT Certification DA Dental models DG Diagnostic report DS Discharge summary EB Explanation of benefits coordination of benefits or Medicare secondary payer MT Models NN Nursing notes OB Operative note OZ Support data for claim PN Physical therapy notes PO Prosthetics or orthotic certification PZ Physical therapy certification RB Radiology films RR Radiology reports RT Report of tests and analysis report 10302 ATTACHMENT TRANS MODE QUAL INVALID PWK02 The qualifier indicating the mode of transmission for the documentation for this claim is invalid Valid Values AA Available on request at provider site This means that the paperwork is not being sent with the claim at this time Instead it is available to the payer or appropriate entity at their request BM By mail EL Electronically only in a separate transaction EM E mail FX By fax
11. Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 51 Edit Edit Description Element Edit Explanation Number Segment ID 10303 ATTACHMENT PWKO5 The qualifier indicating the attachment control number is CONTROL invalid for this claim NUMBER QUAL INVALID Valid Value AC Attachment control number 10304 ATTACHMENT PWKO06 The qualifier indicating the attachment control number is CONTROL missing for this claim If indicating the support NUMBER documentation is being sent by fax e mail or electronically QUAL MISSING in a separate transaction the attachment control number qualifier is required Valid Values AA Available on request at provider site BM By mail EL Electronically only EM E mail FX By fax 10305 ATTACHMENT PWKO6 The attachment control number is invalid for this claim CONTROL NUMBER INVALID 10307 ENCNTR CN101 The qualifier indicating the type of contract for encounter CNTRCT TYPE claims is invalid for this claim CODE INVALID Valid Values 02 Per diem 03 Variable per diem 04 Flat 05 Capitated 06 Percent 09 Other This information is not used for DMERC 10309 PAT PAID AMT AMT The segment providing the amount the patient paid exceeds SEGMENT EXC maximum use If this information is reported only 1 MAX USE occurrence per claim may be used 10310 NOT USED 10311 PURCH SVC AMT The segment providing the total purchased service amount AMT exceeds maxi
12. cccccccccseeeeceeeeeeeeeeeesteeneeeesnneeees 1 Medicare Edit Numbers 20001 20049 a arn er te a A a aa a ee 2 20050 20099 s sate gee a R E a 8 AO E 0H Cie EE ET RE 16 20150 20192 eiis i ea a a a 25 Chapter Nine Front End Edits DMERC eseesseerrssrerrererrerrrrereerrre rn 1 DMERC Edit Numbers 4000140024 niinen aa iai aia aee cn Weds haeba aoi aiet 2 40025 AQUA Jesper gueren dente eae ee EEE a Aa ein ENAT 4 40050400 4n a a eal eta a 6 40075 4008 nn naia a ei e A EE E tai tcy 9 Chapter Ten Contact Information sseeeeeeseeeirsrserrsreerrsrrrrrserirsrererrisrerrnrerrnstne 1 Appendix e DMERC Region D Companion Document Trading Partner Agreement Glossary Index Region D DMERC EDI Manual Revised April 2003 Introduction Congratulations on your recent decision to start billing electronically Electronic Media Claims EMC is transmitting your claims via computer rather than submitting your claims on paper MCM 5240C The Region D DMERC EDI Manual has been developed to assist electronic billers in successfully transmitting their Region D DMERC claims to CIGNA Medicare Below is an overview of what you can expect to find in this manual When you elect to transmit your claims electronically you open yourself up to many opportunities that will ultimately benefit your business by improving your processes Chapter 1 identifies the various benefits of billing electronically As an existing biller one of the benefits of
13. www cignamedicare com edi Revised April 2003 Page 96 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10516 ID CODE NM108 The qualifier identifying the other payer identification number QUALIFIER for this line is invalid INVALID This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare OR This information is used for Medigap secondary to Medicare claims and should not be submitted unless there is an approved Medigap policy held by this subscriber Valid Values PI Payer identification XV Health Care Financing Administration National Plan ID 10517 ADD OTH PAY N2 The segment providing additional other payer name NAME EXC information for this claim exceeds maximum use When this MAX USE information is reported only 1 occurrence per transaction may be used This information is not used for DMERC 10518 CONTACT FUN PERO1 The qualifier for the other payer contact information for this CODE INVALID claim is invalid for this subscriber Valid Value IC Information contact This information is not used for DMERC 10519 OTH PAY PERO2 The other payer contact person s name is missing for this CONT NAME subscriber A contact name for the other payer must be MISSING submitted when reporting other payer information This information is used for Medicare Secondary Payer
14. 13 7 2000 10 09 09 59 16 DOWNLOAD END COMPLETED SUCCESSFULLY 2000 10 09 09 59 27 DOWNLOAD START gt FXF_7 gt fxf gt ND_XATO gt MOO1A0 2000 09 21 11 21 09 7 2000 10 09 10 00 12 DOWNLOAD END COMPLETED SUCCESSFULLY 2000 10 09 10 00 24 DOWNLOAD START gt FXF_7 gt fxf gt ND_XATO gt MOO1A0 2000 09 21 11 21 03 7 2000 10 09 10 01 12 DOWNLOAD END Attempt ABORTED Transfer cancelled by us ter 2000 10 09 10 01 27 DOWNLOAD START gt FXF_7 gt fxf gt ND_XATO gt MOO1A0 2000 09 21 11 21 03 7 f1 2000 10 09 10 01 44 DOWNLOAD END COMPLETED SUCCESSFULLY 2000 10 09 10 02 08 LOGOUT ASYNC telnet_ew 25 MBOO1A PAUSE Press lt CR gt to continue or q to quit Region D DMERC EDI Manual Revised June 2002 Stratus Network User Guide Page 27 Explanation of the Activity Log Each line begins with a Date and Time Stamp All times are recorded in Eastern Time Files that have been successfully received prior to 5 00 p m will be processed on the same day Files received after 5 00 p m will be processed the following business day The first line LOGIN indicates that your connection was successful The string of characters after it describes details about the type of connection you established The following lines indicates the action that was being attempted You will either see UPLOAD when you send us a file o DOWNLOAD when you receive a file from us It is important to have both a START and END line for each action If the END li
15. 1H CHAMPUS identification number El Employer s Identification Number G2 Provider commercial number LU Location number N5 Provider plan network identification number SY Social Security Number X5 State industrial accident provider number This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 145 Edit Edit Description Element Edit Explanation Number Segment ID 10793 REND PROV REF02 The rendering provider secondary identification number is SEC ID missing for this line MISSING This information is not used for DMERC 10794 PUR SER NM1 The segment providing the purchased service provider PROV NAME name information for this line exceeds maximum use When EXC MAX USE this information is reported only 1 occurrence per line may be used This information is not used for DMERC 10795 ENTITY ID NM101 The qualifier identifying the purchased service provider for CODE INVALID this line is invalid Valid Value QB Purchase service provider This information is not used for DMERC 10796 ENTITY TYPE NM102 The qualifier identifying the purchased service provider type QUALIFIER is invalid for this line INVALID Valid Values 1 Person 2 Non person entity This information is not used for DMERC 10797 ID CODE NM108 The qualifier identifying the purchased service provider QUALIFIER identification number for this line is invalid INVALID Val
16. Element D Edit Explanation 20169 REFERRING NM103 The referring provider s last name was entered in an PROVIDER LAST invalid format Verify the first position of the referring NAME INVALID provider s last name is not a space and only contains alpha characters This information is not used for DMERC 20171 TOTAL CLAIM CLM02 The value entered as the total claim charges is invalid CHARGE gt The total claim charges cannot exceed 99 999 99 99 999 99 20172 LINE CHARGE gt SV102 The amount entered for this line item charge exceeds 99 999 99 99 999 99 20173 TOTAL CLM CLM02 The total claim charge amount is missing on this claim CHARGE AMT This is a required element on each claim and must MISSING equal the sum of all service line charges 20174 SVC LINE CHARGE SV102 The service line charge amount is missing on this line AMT MISSING This is a required element on each service line Region D DMERC EDI Manual Revised April 2003 Front End Edits Medicare Page 29 Edit Number EDIT DESCRIPTION Element ID Edit Explanation 20175 BILLING PROV ID QUAL INVALID NM108 The qualifier used to indicate the billing provider s primary identification number is invalid Valid values 24 Employer s identification number 34 Social Security Number XX National Provider Identifier 20176 PAY TO PROV ID QUAL INVALID NM108 The qualifier used to indicate the pay to provider s prima
17. INVALLID 40058 ORDERING N302 The ordering provider s additional address information listed PROVIDER on this claim was entered in an invalid format Verify the first ADDRESS2 position of the additional address information does not INVALID contain a space Region D DMERC EDI Manual Revised April 2003 Front End Edits DMERC Page 7 Edit EDIT Element Edit Explanation Number DESCRIPTION ID 40066 INVALID LQ02 The DMERC CMN form number entered is not a valid form UNNECESSARY number for the HCPCS code submitted on this line Verify the CMN SUBMITTED CMN form number is entered as it appears on the CMN Do not include the alpha character Valid Values 01 02 02 03 03 02 04 03 06 02 07 02 08 02 09 02 10 02 40067 INVALID LQ02 The DMERC CMN version number entered is not a valid UNNECESSARY version number for the HCPCS code submitted on this line CMN VERSION Verify the version number is entered as it appears on the SUBMITTED CMN Do not include the alpha character Valid Values 01 02 02 03 03 02 04 03 06 02 07 02 08 02 09 02 10 02 40068 QUESTION FRMO1 The question number entered is not valid for the DMERC NUMBER LETTER CMN form being sent with this claim line INVALID 40069 NOT USED 40070 QUESTION FRMO03 The question response for this CMN was entered in an invalid RESPONSE format If you have indicated the question is to be answered INVALID using a text response the first position
18. TAXONOMY When this information is sent you must included the PRV CODE segment and include the provider s taxonomy code MISSING 11133 PROVIDER PRV03 The billing provider s taxonomy code indicated for this SPECIALITY transaction is invalid Verify the taxonomy code submitted CODE INVALID against the taxonomy code list published by Washington Publishing Company To obtain a copy of this list visit their Web site at www wpc edi com This information is not used for DMERC 11134 RENDERING PRV03 The rendering provider s taxonomy code indicated for this PROV claim is invalid Verify the taxonomy code submitted against SPECIALITY the taxonomy code list published by Washington Publishing CODE INVALID Company To obtain a copy of this list visit their Web site at www wpc edi com This information is not used for DMERC 11135 REFERRING PRV03 The referring provider s taxonomy code indicated for this PROV claim is invalid Verify the taxonomy code submitted against SPECIALITY the taxonomy code list published by Washington Publishing CODE INVALID Company To obtain a copy of this list visit their Web site at www wpc edi com This information is not used for DMERC 11136 RENDERING PRV03 The rendering provider s taxonomy code indicated for this PROVIDER line is invalid Verify the taxonomy code submitted against SPECIALITY the taxonomy code list published by Washington Publishing INVALID Company To obtain a copy of this list visit their Web site at www wpc
19. 10815 CANNOT SEND NM1 The segment providing the supervising provider name gt 1 SPV PROV information for this line exceeds maximum use When this NAME information is reported only 1 occurrence per line may be SEGMENT used This information is not used for DMERC 10816 SPV PROV ID NM101 The qualifier identifying the supervising physician for this CODE INVALID line is invalid Valid Value DQ Supervising physician This information is not used for DMERC 10817 SPV PROV NM102 The qualifier identifying the supervising physician type is NAME invalid for this line QUALIFIER INVALID Valid Value 1 Person This information is not used for DMERC 10818 SPV PROV NM103 The last name is missing for this line If you have specified LAST NAME the supervising provider type to be a person this element MISSING must contain the last name of that person This information is not used for DMERC 10819 SPV PROV NM104 The first name of the supervising provider is missing for this FIRST NAME line If you have specified the supervising provider type to be MISSING a person this element must contain the first name of that person This information is not used for DMERC 10820 SPV PROV ID NM108 The qualifier identifying the supervising provider s CODE identification number for this line is invalid QUALIFIER INVALID Valid Values 24 Employers Identification Number 34 Social Security Number XX Health Care Financing Administration National Provi
20. 10839 CANNOT SEND PER The segment containing ordering provider contact gt 1 ORD PROV information exceeds maximum use When this information is CONT INFO reported only 1 occurrence per line may be used SEG 10840 CONTACT PERO1 The qualifier for the ordering provider contact information for FUNCTION this line is invalid for this line CODE INVALID Valid Value IC Information contact 10841 ORD PROV PERO2 The ordering provider s contact person s name is missing for CONTACT this line A contact name for the ordering provider s must be NAME submitted when reporting ordering provider information for MISSING DMERC CMN s 10842 ORD PROV PERO3 The qualifier identifying the type of contact information being COMM NBR provided for the ordering provider is invalid for this line QUALIFER INVALID Valid Values EM Electronic mail FX Facsimile TE Telephone 10843 ORD PROV PERO5 The qualifier identifying the second type of contact PHONE information being provided for the ordering provider is NUMBER invalid for this line INVALID Valid Values EM Electronic mail EX Telephone extension FX Facsimile TE Telephone 10844 ORD PROV PERO7 The qualifier identifying the third type of contact information COMM NBR being provided for the ordering provider is invalid for this QUALIFER line INVALID Valid Values EM Electronic mail EX Telephone extension FX Facsimile TE Telephone www cignamedicare com ed
21. 11 12 Valid Values with Description Functional group not supported the submitted group is not supported by the receiver i e If someone sent us a HP in the GS01 indicating the group was an 835 rather than the HC for 837 X12 level Functional group version GS08 not supported the submitted group is not supported by the receiver i e If someone sent us an earlier version 3051 and we do not support it Functional group trailer missing functional group being acknowledged did not contain a GE segment Group control number in the functional group header and trailer don t match GS0602 must be identical to GE02 Number of included transaction sets does not match actual count GE01 does not equal the number of transaction sets within the GS GE Group control number violates syntax if characters other than that specified for a NO data type is sent i e an alpha character or if it is out of bounds of the Min Max Authentication key name unknown Encryption key name unknown Requested service authentication or encrypted not available 13 Unknown security recipient 14 15 16 Unknown security originator Syntax error in decrypted text Security not supported will send this error when security information is sent ISA03 or ISA04 Incorrect message length encryption only Message authentication code failed S3E security end segment missing for S3S security start segment S3S security start segment m
22. C2 Cervical 2 C3 Cervical 3 C4 Cervical 4 C5 Cervical 5 C6 Cervical 6 C7 Cervical 7 CO Coccyx IL Ilium L1 Lumbar 1 L2 Lumbar 2 L3 Lumbar 3 L4 Lumbar 4 L5 Lumbar 5 OC Occiput SA Sacrum T1 Thoracic 1 T10 Thoracic 10 T11 Thoracic 11 T12 Thoracic 12 T2 Thoracic 2 T3 Thoracic 3 T4 Thoracic 4 T5 Thoracic 5 T6 Thoracic 6 T7 Thoracic 7 T8 Thoracic 8 T9 Thoracic 9 This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 59 Edit Edit Description Element Edit Explanation Number Segment ID 10362 LVL OF CHIRO CR204 The qualifier indicating the level of subluxation on SUBLX CODE 2 chiropractic services is invalid for this claim For claims INVALID involving subluxation this information is required to indicate a range Valid Values C1 Cervical 1 C2 Cervical 2 C3 Cervical 3 C4 Cervical 4 C5 Cervical 5 C6 Cervical 6 C7 Cervical 7 CO Coccyx IL Ilium L1 Lumbar 1 L2 Lumbar 2 L3 Lumbar 3 L4 Lumbar 4 L5 Lumbar 5 OC Occiput SA Sacrum T1 Thoracic 1 T10 Thoracic 10 T11 Thoracic 11 T12 Thoracic 12 T2 Thoracic 2 T3 Thoracic 3 T4 Thoracic 4 T5 Thoracic 5 T6 Thoracic 6 T7 Thoracic 7 T8 Thoracic 8 T9 Thoracic 9 This information is not used for DMERC www cignamedicare com edi Revised April 2
23. LENGTH EXCEEDS MAXIMUM 10992 MED CR303 The length of need as reported on the CMN for this line NECESSITY cannot contain a decimal point LENGTH CANNOT HAVE DEC 10993 MED CR502 The length of need as reported on the oxygen certification NECESSITY form 484 2 exceeds 15 positions LENGTH EXCEEDS MAXIMUM 10994 MED CR502 The length of need as reported on the oxygen certification NECESSITY form 484 2 cannot contain a decimal point LENGTH CANNOT HAVE DEC 10995 ABG LEVEL CR510 The value entered as the arterial blood gas quantity as EXCEEDS reported on the oxygen certification form 484 2 exceeds 15 MAXIMUM positions 10996 ABG LEVEL CR510 The value entered as the arterial blood gas quantity as CANNOT HAVE reported on the oxygen certification form 484 2 cannot gt 2 DEC exceed two positions to the right of the decimal point PLACES 10997 OX SAT LEVEL CR511 The value entered as the oxygen saturation quantity as EXCEEDS reported on the oxygen certification form 484 2 exceeds 15 MAXIMUM positions Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 175 10998 OX SAT LEVEL CR511 The value entered as the oxygen saturation quantity as CANNOT HAVE reported on the oxygen certification form 484 2 cannot gt 2 DEC exceed two positions to the right of the decimal point PLACES 10999 ANESTH QTY02 The value entered as the anesthesia modifying units cannot MODIFYING exceed 15 positions UNITS EXCEEDS Thi
24. Litigation MB Medicare Part B MC Medicaid MI Medigap Part B MP Medicare Primary OT Other PP Personal payment cash no insurance SP Supplemental policy www cignamedicare com edi Revised April 2003 Page 84 Chapter Seven Edit Number Edit Description Element Segment ID Edit Explanation 10468 CLM FILING IND CODE INVALID SBRO9 The qualifier identifying the other payer s insurance plan type for this subscriber is invalid for this claim This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare Valid Values 09 Self pay 10 Central certification 11 Other non federal programs 12 Preferred Provider Organization PPO 13 Point of Service POS 14 Exclusive Provider Organization EPO 15 Indemnity insurance 16 Health Maintenance Organization HMO Medicare Risk AM Automobile medical BL Blue Cross Blue Shield CH Champus Cl Commercial insurance co DS Disability HM Health Maintenance Organization LI Liability LM Liability medical MB Medicare Part B MC Medicaid OF Other federal program TV Title V VA Veteran Administration Plan WC Workers compensation health claim ZZ Mutually defined unknown 10469 CLM LEVEL ADJ EXC MAX USE CAS The segment reporting claim level ad
25. MISSING REF The segment containing additional other payer purchased service provider identification information is missing from this claim This information is used when a payer is submitting this claim to another payer and should not be submitted by the supplier This information is not used for DMERC 10564 REF ID QUALIFIER INVALID REFO1 The qualifier for the other payer purchased service provider secondary identification number information for this claim is invalid This information is used when a payer is submitting this claim to another payer and should not be submitted by the supplier Valid Values 1A Blue Cross provider number 1B Blue Shield provider number 1C Medicare provider number El Employer s Identification Number G2 Provider commercial number LU Location number N5 Provider plan network identification number This information is not used for DMERC 10565 OTH PAY PUR SER PROV ID MISSING REF02 The other payer purchased service provider secondary Identification number is missing for this claim This information is used when a payer is submitting this claim to another payer and should not be submitted by the supplier This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 107 Edit Number Edit Description Element Segment ID Edit Explanation 10566 OTH PAY SER FAC
26. NAME NOT is invalid for this claim USED IN X12 VERS This edit indicates an invalid format and should be resolved by contacting your software vendor This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Page 204 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 11208 PAYOR NM103 You have included the other payer s purchased service LAST ORG provider last name or organization name with this claim NAME NOT This information is invalid for this claim USED IN X12 VERS This edit indicates an invalid format and should be resolved by contacting your software vendor This information is not used for DMERC 11209 PAYOR NM103 You have included the other payer s service facility last LAST ORG name or organization name with this claim This information NAME NOT is invalid for this claim USED IN X12 VERS This edit indicates an invalid format and should be resolved by contacting your software vendor This information is not used for DMERC 11210 PAYOR NM103 You have included the other payer s supervising provider LAST ORG last name or organization name with this claim This NAME NOT information is invalid for this claim USED IN X12 VERS This edit indicates an invalid format and should be resolved by contacting your software vendor This information is not used for DMERC 11211 PROD SER ID SV101 1 The qualifier indicating the type of product
27. Page 180 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 11032 PD SVC CNT SVD05 The value entered as the line adjudication Information paid VALUE service unit count is invalid If reported do not exceed the EXCEEDS MAX maximum number of positions to the right of the decimal DEC PLACES point This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 11033 ADJ AMOUNT CAS03 The value entered as the line adjustment amount is invalid EXCEEDS If reported this amount cannot exceed 18 positions MAXIMUM This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 11034 ADJ AMOUNT CAS03 The value entered as the line adjustment amount is invalid CANNOT HAVE If reported this amount cannot exceed two positions to the gt 2 DEC right of the decimal point PLACES This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 11035 ADJUSTED CAS04 The amount entered as the line adjusted unit claim level is UNITS invalid If reported this amount cannot exceed 15 positions EXCEEDS MAXIMUM This information is used for Medicare Secondary Payer claims and should not be submitte
28. R Reader Program A software program which is designed for the purpose of converting raw data to a recognizable format for interpretation 2S Segment An intermediate unit of information in a transaction set A segment contains logically related data elements in a defined sequence which can be used in one or more business transactions it consists of a segment identifier which is not a data element one or more data elements delimited by a data element separator and a segment terminator The data segment is always defined as variable length with the exception of the very first segment within the transaction Segments may repeat up to a specified number of times and may be optional or mandatory within the transaction set www cignamedicare com edi G 4 Glossary Stratus An asynchronous transmission mailbox system that allows users to dial directly into CIGNA Medicare s Gateway Service This network is used to transmit claims and download reports Submitter ID An identification number assigned by the DMERC Electronic Data Interchange department to identify electronic billers DMERC bille rs will be issued one Submitter ID that may be used to transmit claims to any of the four DMERCs Subscriber The individual for whom the Medicare claim is being submitted This individual is also referred to as the Medicare beneficiary For Medicare claim purposes the beneficiary is always the subscriber Taxonomy Code A code that identifies th
29. Set User Default Change Data Type Number of Files List file names View a file PoONr O i gt Upload Put a 7 Display Activity Log FEEEAAEEAEEEAHEEE Mailbox Access Facility User Id MBOO1A s Current Settings DATA TYPE SEND_ANSITEST MAILBOX SD_CATI INBOUND PROTOCOL PROMPT file in Mailbox FILE TYPE STREAM PRINTER_PAUSE NO INITIAL MENU OPT NONE 99 Return to main menu Network 7 ENTER YOUR SELECTION Region D DMERC EDI Manual Revised June 2002 Stratus Network User Guide Page 11 2 This will bring you to the Edit User Profile menu Each default is listed with the current defaults in parentheses These defaults are also displayed on the Mailbox Access Facility menu Ae eate eee eae ee teeteete pdit User Profile ttttteeeeee eee eeeeaae 1 Set PROTOCOL default n lt Values in parentheses 2 Set FILE TYPE default s are current defaults 3 Set PRINTER PAUSE default n as selected by user 4 Set INITIAL MENU default n 5 Set DATA TYPE default 7 99 Return to Main Menu ENTER YOUR SELECTION 3 From the Edit User Profile menu type 1 to select the Protocol default A menu listing modem protocol options will appear Choose PROTOCOL default x Y Z i K N XMODEM YMODEM ZMODEM XMODEMLK KERMIT NONE Always prompt me our uw ue Q QUIT Return to previous menu Select PROTOCOL default
30. look to the right under the column heading ST and or TX e The amount billed e The status of the claim A accepted for processing R rejected due to data errors T transferred to another DMERC for processing e Transferred claims A transferred to Region A for processing B transferred to Region B for processing C transferred to Region C for processing e The level at which the errors occurred if the claim was rejected IN cerror occurred at the interchange level For example if you did not include the receiver s identification code the DMERC s carrier code in the submitted transaction An error at this level will require the entire file to be retransmitted once the error is corrected FG error occurred at the functional group level At this time there are no edits that will cause an FG to be present in this field TS error occurred at the transaction set level For example if an invalid submitter identification number was used The error would need to be corrected and the 837 transaction would need to be retransmitted BP error occurred at the billing pay to provider level For example if a billing provider supplier number was transmitted before it was set up to transmit electronic claims to Region D DMERC If an edit occurs at this level correct the error that occurred and retransmit every claim for the affected supplier SP error occurred at the beneficiary patie
31. s last name was entered in an invalid NAME INVALID format Verify the first position of the subscriber s last name is an alpha character and does not contain spaces Make sure the first three positions of the subscriber s last name are not any of the following MR MR DR DR JR or JR 20022 SUBSCRIBER FIRST NM104 The subscriber s first name was entered in an invalid NAME INVALID format Verify the first position of the subscriber s first name does not contain a space and the name only contains alpha characters 20023 SUBSCRIBER NM105 The subscriber s middle name was entered in an invalid MIDDLE NAME format Verify only alpha characters are present INVALID 20024 SUBSCRIBER ID NM108 The qualifier identifying the subscriber identification CODE QUALIFIER INVALID number for this claim is invalid Valid Value MI Member Identification Number Region D DMERC EDI Manual Revised April 2003 Front End Edits Medicare Page 5 Edit Number EDIT DESCRIPTION ElementID Edit Explanation 20025 SUBSCRIBER ID NM109 The subscriber s Health Insurance Claim Number CODE INVALID HICN indicated for this claim was entered in an invalid format Verify the HICN was entered exactly as it appears on the Medicare beneficiary s red white and blue Medicare card 20026 SUBSCRIBER N301 The subscriber s address listed on this claim was ADDRESS1 INVALID entered in an invalid format Verify the
32. www cignamedicare com edi Revised April 2003 Page 144 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10788 PROV CODE PRVO1 The qualifier identifying the type of provider being reported INVALID for this line is invalid Valid Value PE Performing This information is not used for DMERC 10789 ID CODE PRV02 The qualifier identifying the type of identification number QUALIFIER being reported for the rendering provider is invalid for this INVALID line Valid Value ZZ Mutually Defined Provider Taxonomy Code This information is not used for DMERC 10790 ADD REND N2 The segment providing additional rendering provider name PROV NAME information for this claim exceeds maximum use When this INFO EXC MAX information is reported only 1 occurrence per transaction USE may be used This information is not used for DMERC 10791 REND PROV REF The segment containing additional rendering provider SEC ID EXC Identification information exceeds maximum use When this MAX USE information is reported only 5 occurrences per line may be used This information is not used for DMERC 10792 REF ID REFO1 The qualifier for the rendering provider secondary QUALIFIER identification number information for this line is invalid INVALID Valid Values OB State license number 1B Blue Shield provider number 1C Medicare Provider Number 1D Medicaid provider number 1G Provider UPIN number
33. www cignamedicare com edi Revised April 2003 Page 164 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10910 TREATMENT CR206 The value representing the treatment series period cannot PERIOD CNT contain a decimal point CANNOT HAVE DECIMAL This information is not used for DMERC 10911 MONTHLY CR207 The value representing the spinal manipulation monthly TREAT CNT treatment count exceeds 15 positions CANNOT BE gt 15 POS This information is not used for DMERC 10912 MONTHLY CR207 The value representing the spinal manipulation monthly TREAT CNT treatment count cannot contain a decimal CANNOT HAVE DECIMAL This information is not used for DMERC 10913 ALLOW AMT HCP02 The value representing the claim repricing allowed amount PRICING exceeds 18 positions EXCEEDS MAXIMUM This information is not used for DMERC 10914 ALLOW AMT HCP02 The value representing the claim repricing allowed amount PRICING exceeds two positions to the right of the decimal point CANNOT HAVE gt 2 DEC This information is not used for DMERC 10915 SAVINGS AMT HCP03 The value representing the claim repricing savings amount PRICING exceeds 18 positions EXCEEDS MAXIMUM This information is not used for DMERC 10916 SAVINGS AMT HCP03 The value representing the claim repricing savings amount PRICING exceeds two positions to the right of the decimal point CANNOT HAVE gt 2 DEC This information is n
34. 1 occurrence per claim may be used This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10474 NOT USED 10475 COB AMT The segment providing the amount the primary payer ALLOWED AMT allowed exceeds maximum use If this information is EXC MAX USE reported only 1 occurrence per claim may be used This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10476 NOT USED www cignamedicare com edi Revised April 2003 Page 86 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10477 COB PAT AMT The segment providing the amount the patient is responsible RESP AMT for to the other payer exceeds maximum use If this EXC MAX USE information is reported only 1 occurrence per claim may be used This information is used when a payer is submitting this claim to another payer and should not be submitted by the supplier 10478 NOT USED 10479 COB AMT The segment providing the amount the other payer covered COVERED exceeds maximum use If this information is reported only 1 AMT EXC MAX occurrence per claim may be used USE This information is used when a payer is submitting this claim to another payer and should not be submitted by the supplier
35. 8 and 9 for edit explanations C Line number within the claim that this error Loop sequence within the transaction set L Data element position within the segment occurred on submitted containing this claim containing data that caused this edit Segment containing the data that received Data element name for the element this edit containing data that caused this edit Edit description Refer to Chapters 7 8 and 9 for edit explanations Page 24 Chapter Six Report 716006 CMN Reject Listing The CMN Reject Listing report is included in the Electronic Report Package if there were one or more CMNs are rejected off of a claim The CMN Regct Listing report lists any CMNs that were rejected after the claim was accepted into our system Information present on this report includes HICN This is the HICN for the beneficiary for whom the CMN was rejected CCN Claim Control Number This is the CCN of the claim the CMN was rejected from Please note since a CCN was assigned to the claim the claim will be processed and depending on the CMN rejection code listed on this report the claim may be denied Procedure code The procedure code submitted on the claim for which the CMN was rejected Original initial date This is the initial date Region D DMERC has on file This date can be very useful in determining and correcting the CMN rejects Submitted initial date This is the initial date the billing provider submit
36. ILL SYM DTP03 The date of similar symptoms or Illness entered is invalid for ONSET DATE this line When entered this information must not be greater FUTURE DATE than today s date This information is not used for DMERC 10721 QUANTITY QTY01 The qualifier indicating anesthesia modifying units is invalid QUALIFIER for this line INVALID Valid Values BF Age modifying units EC Use of extracorporeal circulation EM Emergency modifying units HM Use of hypothermnia HO Use of hypotension HP Use of hyperbaric pressurization P3 Physical status III P4 Physical status IV P5 Physical status V SG Swan Ganz This information is not used for DMERC 10722 ANESTH MOD QTY02 The number of anesthesia modifying units is missing You UNITS have indicated anesthesia units are being reported however MISSING have not included any units with this line This information is not used for DMERC 10723 MEAS REF ID MEA01 The qualifier indicating the measurement being reported for INVALID this line is invalid Valid Values OG Original starting dosage TR Test results Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 135 Edit Edit Description Element Edit Explanation Number Segment ID 10724 MEAS MEA02 The qualifier identifying the test results or patient s height QUALIFIER being reported for this line is invalid INVALID Valid Values CON Concentration used to report ABG test re
37. L4 Lumbar 4 L5 Lumbar 5 OC Occiput SA Sacrum T1 Thoracic 1 T10 Thoracic 10 T11 Thoracic 11 T12 Thoracic 12 T2 Thoracic 2 T3 Thoracic 3 T4 Thoracic 4 T5 Thoracic 5 T6 Thoracic 6 T7 Thoracic 7 T8 Thoracic 8 T9 Thoracic 9 This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 118 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10609 UNIT BASIS CR205 The qualifier indicating the length of time chiropractic MEASURE treatment has been administered is invalid for this line INVALID Valid Values DA Days MO Months WK Week YR Years This information is not used for DMERC 10610 TREAT PER CR207 The value representing the number of chiropractic MISSING treatments rendered in the month for which this line is being billed is missing This information is not used for DMERC 10611 PAT COND CR208 The patient s condition code indicating the need for spinal CODE INVALID manipulation is invalid for this line Valid Values A Acute condition C Chronic condition D Non acute E Non life threatening F Routine G Symptomatic M Acute manifestation of a chronic condition This information is not used for DMERC 10612 COMP IND CR209 The value representing spinal manipulation complications is INVALID invalid for this line Valid Values N No Y Yes This information is not
38. LMP DT FMT Q DTP02 The qualifier indicating the format used to report the date of INVALID last menstrual period for this claim is invalid Valid Value D8 Date expressed in format CCYYMMDD This information is not used for DMERC 10251 LMP DT DTPO3 The last menstrual period date entered is invalid for this INVALID FMT claim When entered this information must be entered in a CCYYMMDD format This information is not used for DMERC 10252 LMP DT DTPO3 The last menstrual period date entered is invalid for this FUTURE DT claim When entered this information must not be greater than today s date This information is not used for DMERC 10253 LAST X RAY DTP The segment providing the last X ray date for this claim DT SEG EXC exceeds maximum use If this information is reported only 1 MAX USE occurrence per claim may be used This information is not used for DMERC 10254 NOT USED 10255 LAST X RAY DTP02 The qualifier indicating the format used to report the X ray DT FMT Q date for this claim is invalid INVALID Valid Value D8 Date expressed in format CCYYMMDD This information is not used for DMERC 10256 LAST X RAY DTP03 The last X ray date entered is invalid for this claim When DT INVALID entered this information must be entered in a valid FMT CCYYMMDD format This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 45 Edit Edit D
39. Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare This information is not used for DMERC 11047 ADJUSTED CAS13 The value entered as the line adjustment the adjusted units UNITS claim level amount is invalid If entered this amount cannot EXCEEDS exceed 15 positions MAXIMUM This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare This information is not used for DMERC 11048 ADJ UNITS CAS13 The value entered as the line adjustment the adjusted units EXCEEDS MAX claim level amount is invalid If reported do not exceed the DECIMAL maximum number of positions to the right of the decimal PLACES point This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 183 Edit Edit Description Element Edit Explanation Number Segment ID 11049 ADJ AMOUNT CAS15 The value entered as the line adjustment amount is invalid EXCEEDS If reported this amount cannot exceed 18 positions MAXIMUM This information is used for Medicare Secondary Payer claims and should not be submitted unless
40. On file at payer or at plan sponsor Y Yes provider has a signed statement permitting release of medical billing data related to a claim Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 37 Edit Edit Description Element Edit Explanation Number Segment ID 10197 PAT SIGN CLM10 The code specifying the source of the patient s signature is SOURCE missing for this claim If you have indicated that a signature CODE is on file to release any data then you must provide a valid MISSING source of signature Valid Values B Signed signature authorization form or forms for both HCFA 1500 Claim Form block 12 and block 13 are on file C Signed HCFA 1500 Claim Form on file M Signed signature authorization form for HCFA 1500 Claim Form block 13 on file P Signature generated by provider because the patient was not physically present for services S Signed signature authorization form for HCFA 1500 Claim Form block 12 on file 10198 PAT SIGN CLM10 The code identifying the source of the patient s signature is SOURCE invalid for this claim CODE INVALID Valid Values B Signed signature authorization form or forms for both HCFA 1500 Claim Form block 12 and block 13 are on file C Signed HCFA 1500 Claim Form on file M Signed signature authorization form for HCFA 1500 Claim Form block 13 on file P Signature generated by provider because the patient was not physically present for services S Signe
41. REF02 The purchased service provider secondary identification PROV SEC ID number is missing for this line MISSING This information is not used for DMERC 10801 CANNOT SEND NM1 The segment providing the service facility location name or gt 1 SVC oxygen test facility name information for this line exceeds FACILITY maximum use When this information is reported only 1 LOCATION occurrence per line may be used 10802 SVC FACILITY NM101 The qualifier identifying the service facility location or ID CODE oxygen test facility for this line is invalid INVALID Valid Values 77 Service location FA Facility LI Independent lab TL Testing laboratory 10803 SVC FACILITY NM102 The qualifier identifying the service facility location or TYPE oxygen test facility type is invalid for this line QUALIFIER INVALID Valid Value 2 Non person entity 10804 SVC FACILITY NM103 The service facility name is missing or invalid for this line NAME Verify the first position of the service facility or oxygen test MISSING OR facility name does not contain a space and only contains INVALID alpha characters 10805 SVC FACILITY NM108 The qualifier identifying the service facility location or ID QUALIFIER oxygen test facility identification number for this line is INVALID invalid Valid Values 24 Employers Identification Number 34 Social Security Number XX Health Care Financing Administration National Provider Identifier 10806 CANNOT SEND N2 The segm
42. Revised April 2003 Front End Edits DMERC Page 5 Edit EDIT Element Edit Explanation Number DESCRIPTION ID 40038 SERVICE FROM DTPO3 The date entered to indicate the service from date is greater DATE LESS THAN than the subscriber s date of birth PATIENT DOB 40039 FROM DATE DTP03 The date of service entered for this line is invalid Verify if the TO DATE AND HCPCS code has an RR modifier appended to it the service UNITS gt 1 from date and the service to date are equal and the unit of service is equal to 1 40040 CERTIFICATION CRCO1 The value used to indicate the type of certification being sent TYPE INVALID with this line is invalid Valid Values 09 Durable Medicare Equipment Certification 11 Oxygen Therapy Certification 40041 CMN DTPO3 The date entered to indicate the CMN recertification or RECERT REVISED revision date is equal to the date entered to indicate the initial DATE INVALID date on the CMN 40042 CMN DTPO3 The date entered to indicate the CMN recertification or RECERT REVISED revision date is greater than 60 days into the future DATE INVALID 40043 CMN INITIAL DTP The segment containing the CMN initial date is missing If a DATE MISSING CMN is being sent with this claim this is a required segment 40044 CMN DTP The segment containing the date the physician signed the CERTIFICATOIN CMN is missing If a CMN is being sent with this claim this is DATE MISSING a required segment 4
43. SUPPORT FRM04 The date value used to respond to the questions requiring a DOC DATE date response on all DMERC CMN s with the exception of INVALID CMN Form 484 2 is invalid for this line When entered this information must be entered ina CCYYMMDD format Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 161 Edit Edit Description Element Edit Explanation Number Segment ID 10881 SUPPORT FRM04 The date value used to respond to the questions requiring a DOC FUTURE date response on all DMERC CMN s with the exception of DATE INVALID CMN Form 484 2 is invalid for this line When entered this information must not be greater than today s date 10882 SE02 DOES SE02 The ending control number for this transaction set does not NOT MATCH match beginning control number for this transaction set ST02 This edit indicates an invalid format and should be resolved by contacting your software vendor 10883 GE02 DOES GE02 The ending control number for this functional group does not NOT MATCH match beginning control number for this functional group GS02 This edit indicates an invalid format and should be resolved by contacting your software vendor 10884 IEA02 DOES IEA02 The ending control number for this interchange does not NOT MATCH match beginning control number for this interchange ISA13 This edit indicates an invalid format and should be resolved by contacting your so
44. Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare www cignamedicare com edi Revised April 2003 Page 100 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10534 OTH PAY CLM REF The segment containing the other payer claim adjustment ADJ EXC MAX indicator information exceeds maximum use When this USE information is reported only 2 occurrences per transaction may be used This information is used when a payer is submitting this claim to another payer and should not be submitted by the supplier 10535 NOT USED 10536 OTH PAYER REF02 The other payer claim adjustment indicator is missing for CLM ADJ this claim MISSING This information is used when a payer is submitting this claim to another payer and should not be submitted by the supplier Valid Value Y Yes the payer in this loop has previously adjudicated this claim and sent a record of that adjudication to the destination payer 10537 OTH PAYER NM1 The segment providing the other payer patient name PAT INFO EXC information for this claim exceeds maximum use When this MAX USE information is reported only 1 occurrence per claim may be used This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare This information is n
45. TX PURPOSE BHT02 The code specifying the purpose of this transaction is CODE INVALID invalid Medicare only allows for original claims to be submitted Valid Values 00 Original 18 Reissue 10023 TX SEQ BHT03 The number assigned by the submitter to identify this NUMBER transaction is missing This number is assigned by the MISSING submitter and is not used by Medicare however it will be sent back on the 997 functional acknowledgement see Chapter 6 for information on the 997 s and must be unique for each transaction This edit indicates an invalid format and should be resolved by contacting your software vendor 10024 TX CREATE BHT04 The creation date for this transaction set was submitted in DATE INVALID an invalid format The date must be ina CCYYMMDD FORMAT format This edit indicates an invalid format and should be resolved by contacting your software vendor 10025 TX CREATE BHT05 The creation time for this transaction set was submitted in TIME INVALID an invalid format The time must be in a HHMM format FORMAT based on a 24 hour clock This edit indicates an invalid format and should be resolved by contacting your software vendor 10026 TX TYPE BHT06 The code specifying the type of transaction being used is CODE INVALID invalid for this transaction DMERC only allows for chargeable claim transactions Valid Values CH Chargeable RP Reporting www cignamedicare com edi Revised April 2003 Page 10 Chapt
46. This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 11011 POSTAGE AMT02 The value entered as the postage claimed amount is invalid CLMD AMT If entered this amount cannot exceed 18 positions EXCEEDS MAXIMUM This information is not used for DMERC 11012 POSTAGE AMT02 The value entered as the postage claimed amount is invalid CLMD AMT If reported this amount cannot exceed two positions to the CANNOT BE gt 2 right of the decimal point DEC This information is not used for DMERC 11013 PURCH SVC PS102 The value entered as the purchased service charge amount CHG AMT is invalid If reported the amount cannot exceed 18 EXCEEDS positions MAXIMUM This information is not used by DMERC 11014 PURCH SVC PS102 The value entered as the purchased service charge amount CHG AMT is invalid If reported this amount cannot exceed two CANNOT HAVE positions to the right of the decimal point gt 2 DEC This information is not used by DMERC 11015 NBR OF VISITS HSD02 The value entered as the health care services delivery EXCEEDS number of visits is invalid If reported this amount cannot MAXIMUM exceed 15 positions This information is not used by DMERC 11016 NBR OF VISITS HSD02 The value entered as the health care services delivery CANNOT HAVE number of visits is invalid If entered this amount cannot DECIMAL contain a decimal po
47. X 004010X 098 ST 837 000000001 AK1 H C 000000002 AK2 837 0002 AK3 N M 1 000038 8 AK4 01 007 000000001 AK5 R 5 AK9 R 000001 000001 000000 SE 0000000012 000000 001 GE 1 000000001 4 EA 1 000000001 ISA 00 00 ZZ 05655 BAe ae 1638 U 00401 000 gt H GS HC 05655 MB A 20010730 00001638 000000001 X 004010X098 ST 837 000000001 AK1 HC 000000002 A ISA06 997 Sender Identification Number m akso AK2 83 7 0062 P ISA08 997 Receiver Identification Number IN akoor IR P Pa ISA09 997 Creation Date o AK902 AK3 N M 1 000038 8 AK903 AK904 ISA13 Interchange Control Number uy Assigned by CIGNA Medicare for this 997 AK4 01 007 000000001 ISA15 997 Test Production Indicator elements within a segment AK302 separate components in a sub element Segment Terminator Used to indicate the T AK304 end of a segment AK101 u AK401 AK102 AK402 AK201 w AK403 L AK202 AK502 mA A AK5 R S AK9 R 000001 P 000000 SE 0000000012 000000001 GE 1 000000001 IEA 1 000000001 Element Separator Used to separate D AK301 ISA16 Sub Element Separator Used to s Example Accepted 997 ISA 00 00 ZZ05655 ZZ4M BOOLA 011001 1045 U 00401 000000001 0 T GS H C 05655 M BOO1A 20011001 00001045 000000001 X 004010X ee ee ee C 000000002 AK2 837 0002 AK5 A AK9 A 000001 000001 000001 SE 0000000006 000000001 GE 1 00000000L IEA Aa oe ZZ 05655 ZZ M a a vaslan GSH C 05655 M B001A 20011001 00001045 0000000
48. by contacting your software vendor www cignamedicare com edi Revised April 2003 Page 6 Chapter Seven DATE FUTURE DATE Edit Edit Description Element Edit Explanation Number Segment ID 10005 IN SENDER ID ISA05 The qualifier indicating the sender of this interchange is QUAL INVALID invalid This element requires one of the following valid values to be present Valid Values 01 Duns Duns and Bradstreet 14 Duns Plus Suffix 20 Health Industry Number 27 Carrier ID Number assigned by HCFA 28 Fiscal Intermediary ID assigned by HCFA 29 Medicare Supplier number assigned by HCFA 30 US Federal Tax ID 33 National Association of Insurance Commissioners Company Code NAIC ZZ Mutually Defined 10006 IN RECIEVER ISA07 The qualifier indicating the receiver of this interchange is ID QUAL invalid This element requires one of the following valid INVALID values to be present Valid Values 01 Duns Duns and Bradstreet 14 Duns plus suffix 20 Health industry number 27 Carrier ID number assigned by HCFA 28 Fiscal Intermediary ID assigned by HCFA 29 Medicare supplier number assigned by HCFA 30 US Federal Tax ID 33 National Association of Insurance Commissioners Company Code NAIC ZZ Mutually defined 10007 IN CREATE ISA09 The creation date entered is invalid for this interchange This DATE INVALID information must be entered in a YYMMDD format This edit indicates an invalid
49. call the Public Relations Department in Boise The recertification or revised CMN transmitted electronically cannot be accepted for this procedure code The initial CMN on file for this procedure code has been discontinued Any CMN in a discontinued status cannot be recertified or revised For example if a beneficiary had been renting a KO001 wheelchair and then their medical need changed and now they qualified for a KO011 wheelchair CIGNA Medicare would set the KO001 CMN to be discontinued Resolution lf this happens contact the beneficiary physician and or other supplier Check your own files and if it still cannot be resolved call the Public Relations Department in Boise The revision CMN that was transmitted electronically cannot be accepted for this procedure code The CMN on file for this procedure code has been closed Any CMN in a closed status cannot be revised For example if the item was an inexpensive or routinely purchased piece of durable medical equipment such as a Power Operated Vehicle and it had reached the purchased price CIGNA Medicare would close the CMN since the maximum allowed had been paid Another example would be if a beneficiary chose the purchase option for a capped rental item In this instance the equipment would belong to the beneficiary in the 14 month and further payment would not be due Resolution Contact the beneficiary physician and or other supplier Check your files to see how many months
50. cannot contain a decimal point CANNOT HAVE DECIMAL This information is not used for DMERC 10985 TREATMENT CR202 The value representing the chiropractic treatment total count CNT EXCEEDS exceeds 15 positions MAXIMUM This information is not used for DMERC 10986 TREATMENT CR202 The value representing the chiropractic treatment total count CNT CANNOT cannot contain a decimal point HAVE DECIMAL This information is not used for DMERC 10987 TREATMENT CR206 The value representing the chiropractic treatment period PERIOD CNT count exceeds 15 positions EXCEEDS MAXIMUM This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 174 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10988 TREATMENT CR206 The value representing the chiropractic treatment period PERIOD CNT count cannot contain a decimal point CANNOT HAVE DECIMAL This information is not used for DMERC 10989 MONTHLY CR207 The value representing the chiropractic monthly treatment TREAT CNT count exceeds 15 positions EXCEEDS MAXIMUM This information is not used for DMERC 10990 MONTHLY CR207 The value representing the chiropractic monthly treatment TREAT CNT count cannot contain a decimal point CANNOT HAVE DECIMAL This information is not used for DMERC 10991 MED CR303 The length of need as reported on the CMN for this line NECESSITY exceeds 15 positions
51. claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare OR This information is used for Medigap secondary to Medicare claims and should not be submitted unless there is an approved Medigap policy held by this subscriber This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 97 Edit Edit Description Element Edit Explanation Number Segment ID 10520 COMM PERO3 The qualifier identifying the type of contact information being NUMBER provided for the other payer is invalid for this subscriber QUALIFIER INVALID Valid Values ED Electronic data interchange access number EM Electronic mail FX Facsimile TE Telephone This information is not used for DMERC 10521 COMM PERO5 The qualifier identifying the second type of contact NUMBER information being provided for the Other payer is invalid for QUALIFIER this subscriber INVALID Valid Values ED Electronic data interchange access number EM Electronic mail EX Telephone extension FX Facsimile TE Telephone This information is not used for DMERC 10522 COMM PERO7 The qualifier identifying the third type of contact information NUMBER being provided for the other payer is invalid for this QUALIFIER subscriber INVALID Valid Values ED Electronic data interchange access number EM Electronic mail EX Telephone extension F
52. confined after the ambulance service 04 Patient was moved by stretcher 05 Patient was unconscious or in shock 06 Patient was transported in an emergency situation 07 Patient had to be physically restrained 08 Patient had visible hemorrhaging 09 Ambulance service was medically necessary 60 Transportation was to the nearest facility This information is not used for DMERC 10376 VIS SEG EXC CRC The segment containing vision correction information MAX USE exceeds maximum use If this information is reported only 3 occurrences per claim may be used This information is not used for DMERC 10377 NOT USED 10378 VIS CERT CRC02 The vision certification condition code is invalid for this COND CODE claim INVALID Valid Values N No Y Yes This information is not used for DMERC 10379 VIS COND CRC03 The code indicating the condition causing the need for REAS 1 replacement lenses or frames is invalid INVALID Valid Values L1 General standard of 20 degree or 5 diopter sphere Or cylinder change met L2 Replacement due to loss or theft L3 Replacement due to breakage or damage L4 Replacement due to patient preference L5 Replacement due to medical reason This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 65 Edit Edit Description Element Edit Explanation Number Segment ID 10380 VIS COND CRC04 The code indicating the secondary conditi
53. default is the only default that should be changed Below are the instructions to display all the defaults and to change the protocol default The following table describes each default 1 Set PROTOCOL default 2 Set FILE TYPE default 3 Set PRINTER PAUSE default 4 Set INITIAL MENU default 5 Set DATA TYPE default Use this option to select the modem protocol default such as X Modem 1 K Modem Y Modem Z Modem and Kermit for uploading and downloading your files The current default is n for none If you select NONE as your modem protocol you will be prompted each time you transmit or receive to select one Use this option to select the type of file that will be sent The current default is s for stream Unless arrangements have been made with CIGNA Medicare you should always be sending stream files This option should not be changed Use this option to change the printer pause The current default is n for no Changing this option could result in printing errors This option should not be changed Use this option to change the initial screen It is preset to display the Mailbox Access Facility menu The current default is n for none This option should not be changed Use this option to change the data type The current default is 7 for SEND_ANSI TEST Changing this could result in a file going into the wrong mailbox 1 To display your user defaults type 0 and press Enter FEAAEEEAEEEAEEEE
54. electronic payment report which lists claims that have been paid and or denied The ERN process may permit the provider supplier to utilize automatic posting capability if they use a practice management system Element The smallest named unit of information in the ASC X12 standards An element is almost always defined as variable length with specified minimum and maximum requirements Elements do not repeat and may be optional or mandatory within the segment F Functional Acknowledgment 997 An EDI message sent in response to the receipt of an electronic transaction used to notify the sender that the information was received It acknowledges receipt only and does not imply agreement with acceptance of the content of the transaction Region D DMERC EDI Manual November 2001 Glossary G 3 Implementation Guide Set of standards developed by the ANSI X12N sub committee to specify format and data requirements to be used for the electronic transactions named in the HIPAA Transactions and Code Sets Final Rule These guides are available to download free of charge at www wpc edi com ee Loop The largest named unit of information in a transaction set A loop contains logically related segments in a defined sequence in order to group related information together Loops may repeat up to a specified number of times and may be optional or mandatory based on the usage of the first segment of that loop O Ordering Provider The individua
55. end date of the original CMN on file for the same procedure code This error most often occurs when a beneficiary changes suppliers for rental equipment The initial CMN was already on file from the original supplier and then another initial CMN was transmitted either by the same supplier or subsequent supplier CMNs are categorized in our system by beneficiary not supplier For example ABC Oxygen transmits an initial oxygen CMN for Jane Doe with an initial date of 06 01 00 for a 12 month length of need On 09 01 00 Jane Doe changes suppliers and XYZ Oxygen transmits an initial oxygen CMN with an initial date of 09 01 00 The CMN from XYZ Oxygen would be rejected with an error code of 3031 because the initial oxygen CMN from ABC Oxygen is not scheduled to end until 06 01 01 Resolution In the example above the therapy for the oxygen starts with the initial date the beneficiary needed the oxygen Therefore even if a beneficiary changes suppliers assuming the medical need has not ended the initial date of therapy has not changed The subsequent supplier should have obtained a revised CMN The revised date would be the date the new supplier took over the services for the beneficiary If the oxygen order is the same the CMN does not have to be transmitted with the claim However the subsequent supplier would need to furnish the revised CMN upon request from the DMERC If a change occurred in the medical condition of the beneficiary that has cause
56. entered is invalid for this functional group TIME INVALID This information must be entered in one of the following FORMAT formats HHMM HHMMSS HHMMSSD HHMMSSDD This edit indicates an invalid format and should be resolved by contacting your software vendor 10018 FG RESP GS07 The code identifying the functional group responsible AGENCY agency for this functional group is invalid CODE INVALID Valid Value X ASC X12 This edit indicates an invalid format and should be resolved by contacting your software vendor 10019 X12 VERSION GS08 The ANSI ASC X12 N version code for this functional group CODE is invalid INVALID Valid Values 004010X098 ASC X12 version number 004010X098A1 ASC X12 version number 10020 TX TYPE QUAL STO1 The qualifier identifying the type of transaction set being INVALID submitted is invalid Valid Value 837 Health Care Claim This edit indicates an invalid format and should be resolved by contacting your software vendor Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 9 Edit Edit Description Element Edit Explanation Number Segment ID 10021 X12 HL TYPE BHTO1 The code specifying the type of X12 hierarchical structure CODE INVALID within the transaction set is invalid Valid Value 0019 Information Source Subscriber Dependant This edit indicates an invalid format and should be resolved by contacting your software vendor 10022
57. for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Medicare Page 9 Edit Number EDIT DESCRIPTION ElementID Edit Explanation 20062 DIAGNOSIS 6 HI06 2 The sixth diagnosis code indicated on this claim is INVALID invalid Verify the diagnosis code submitted on this claim is a valid ICD 9 diagnosis code This information is not used for DMERC 20063 DIAGNOSIS 7 HI07 2 The seventh diagnosis code indicated on this claim is INVALID invalid Verify the diagnosis code submitted on this claim is a valid ICD 9 diagnosis code This information is not used for DMERC 20064 DIAGNOSIS 8 HI08 2 The eighth diagnosis code indicated on this claim is INVALID invalid Verify the diagnosis code submitted on this claim is a valid ICD 9 diagnosis code This information is not used for DMERC 20065 REFERRING PROV PRV03 The referring provider s taxonomy code indicated for SPECIALTY CODE this claim is invalid Verify the taxonomy code INVALID submitted against the taxonomy code list published by Washington Publishing Company To obtain a copy of this list visit their Web site at www wpc edi com This information is not used for DMERC 20066 RENDERING NM103 The rendering provider s last name was entered in an PROV ORG NAME invalid format Verify the first position of the rendering INVALID provider s last name is an alpha character and does not contain spaces Make sure the first three positions of th
58. for DMERC and the information is not needed for another payer please remove the erroneous data and resubmit the file If the data is needed for another payer please correct the claim and retransmit We have also noted those elements that contain data specific to Medicare Secondary Payer Medigap and Payer to Payer transactions These elements should not be used unless the specific condition is met Payer to Payer elements should never be submitted to DMERC by a supplier Key to Manual NOT USED These edits are currently not used but may be added at a later date www cignamedicare com edi Revised April 2003 Page 2 Chapter Eight Edit Number EDIT DESCRIPTION ElementID Edit Explanation 20001 INTERCHANGE ID ISA07 The qualifier indicating the receiver of this interchange QUALIFIER INVALID is invalid Valid Values 27 Carrier Identification Number as assigned by Health Care Financing Administration HCFA 20002 INTERCHANGE ISA08 The Interchange Control Receiver number is invalid RECEIVER ID This must be a valid Carrier ID assigned by the Health INVALID Care Financing Administration HCFA Valid DMERC Carrier Code 05655 Region D 20003 TEST PRODUCTION ISA15 The test production indicator for this interchange is INDICATOR INVALID invalid Valid Values P Production T Test 20004 SUBMITTER ID NM109 The submitter identification number indicated for this INVALID transaction is invalid Verify th
59. for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare This information is used for Medigap secondary to Medicare claims and should not be submitted unless there is an approved Medigap policy held by this subscriber Valid Values F Female M Male U Unknown 10496 OTH INS COV INFOR MISSING Ol The segment providing other insurance coverage information for this claim is missing This information is required when information for the other subscriber is sent This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare This information is used for Medigap secondary to Medicare claims and should not be submitted unless there is an approved Medigap policy held by this subscriber Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 89 Edit Number Edit Description Element Segment ID Edit Explanation 10497 BEN ASSIG CERT IND INVALID O103 The other insurance benefits assignment indicator is invalid for this claim Use Y to indicate insured authorizes benefits to be paid to the supplier An N response indicates benefits have not been assigned to the supplier This information is used for Medicare Secondary Payer claims and should not be submitted
60. for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10933 ADJ AMOUNT CASO09 The value representing the claim level adjusted amount EXCEEDS exceeds 18 positions MAXIMUM This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10934 ADJ AMOUNT CASO09 The value representing the claim level adjusted amount CANNOT HAVE exceeds two positions to the right of the decimal point gt 2 DEC PLACES This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 167 Edit Edit Description Element Edit Explanation Number Segment ID 10935 ADJUSTED CAS10 The value representing the claim level adjusted units of UNITS service exceeds 15 positions EXCEEDS MAXIMUM This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10936 ADJ UNITS CAS10 The value representing the claim level adjusted units of EXCEEDS MAX service exceeds the maximum number of positions to the DECIMAL right of the decimal point PLACES This information i
61. for Medigap secondary to Medicare claims and should not be submitted unless there is an approved Medigap policy held by this subscriber 20093 REMARK CODE1 MOA03 The remark code indicated on this claim is invalid INVALID Verify the correct code was entered off of the primary payer s electronic remittance advice This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare www cignamedicare com edi Revised April 2003 Page 14 Chapter Eight Edit Number EDIT DESCRIPTION Element ID Edit Explanation 20094 REMARK CODE2 INVALID MOA04 The remark code indicated on this claim is invalid Verify the correct code was entered off of the primary payer s electronic remittance advice This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 20095 REMARK CODE3 INVALID MOA05 The remark code indicated on this claim is invalid Verify the correct code was entered off of the primary payer s electronic remittance advice This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 20096 REMARK CODE 4 INVALID MOA06 The remark code indicated on
62. for help on internal commands 13 At the Main Menu type 1 to select the Mailbox Access Facility menu and press Enter Region D DMERC EDI Manual Revised June 2002 Stratus Network User Guide Page 9 Mailbox Access Facility Menu The Mailbox Access Facility menu allows you to select from several options and provides a view of the current settings for your mailbox The Current Settings box is located on the right side of the screen Always verify the settings before selecting an option tttteeteeeeteeeet Mailbox Access Facility tt tttetttaeee User Id MBOO1A 0 Set User Defaults t Current Settings 1 Change Data Type 2 Number of Files DATA TYPE SEND_ANSITEST 3 List file names MAILBOX SD_CATI INBOUND 4 View a file lhestesestentestestertentertentertesbeatestehetetetetetebatetetetatetetetatatates PROTOCOL PROMPT 6 Upload Put a file in Mailbox FILE TYPE STREAM 7 Display Activity Log PRINTER_PAUSE NO INITIAL MENU OPT NONE 4 99 Return to main menu Network 7 ENTER YOUR SELECTION www cignamedicare con edi Revised June 2002 Page 10 Chapter Five Mailbox Access Facility Menu Option 0 Set User Defaults The user defaults have been preset for your convenience and are displayed in the bottom half of the Current Settings box In most cases changing the user defaults is not recommended The protocol
63. for this INFORMATION interchange is invalid This element requires one of the QUAL INVALID following valid values to be present Valid Values 00 No Authorization Information Present 03 Additional Data Identification This edit indicates an invalid format and should be resolved by contacting your software vendor 10002 IN AUTH ISA02 The authorization information is missing for this interchange INFORMATION If you indicated that authorization information is present MISSING then this element must be filled with 10 alpha numeric characters If you indicated no authorization information is submitted then this must be spaces This edit indicates an invalid format and should be resolved by contacting your software vendor 10003 IN SECURITY ISA03 The qualifier indicating security information for this INFORMATION interchange is invalid This element requires one of the QUAL INVALID following valid values to be present Valid Values 00 No security information present 01 Password This edit indicates an invalid format and should be resolved by contacting your software vendor 10004 IN SECURITY ISA04 The security information is missing for this interchange If INFORMATION you indicated that security information is present then this MISSING element must be filled with 10 alpha numeric characters If you indicated no security information is submitted then this must be spaces This edit indicates an invalid format and should be resolved
64. in a CCYYMMDD format This information is not used for DMERC www cignamedicare com edi Revised April 2003 Front End Edits Page 132 Edit Edit Description Element Edit Explanation Number Segment ID 10700 SYMPT ILLNES DTPO3 The onset of current symptom or illness date entered is S DATE invalid for this line When entered this information must not FUTURE DATE be greater than today s date This information is not used for DMERC 10701 LAST XRAY DT DTP The segment providing the last X ray date for this line EXC MAX USE exceeds maximum use When this information is reported only 1 occurrence per line may be used This information is not used for DMERC 10702 NOT USED 10703 DTE TIME PER DTP02 The qualifier indicating the format used to report the last X FORMAT ray date for this line is invalid QUALIFIER INVALID Valid Value D8 Date expressed in format CCYYMMDD This information is not used for DMERC 10704 LAST XRAY DTP03 The last X ray date entered is invalid for this line When DATE INVALID entered this information must be entered ina CCYYMMDD format This information is not used for DMERC 10705 LAST XRAY DTP03 The last X ray date entered is invalid for this line When DATE FUTURE entered this information must not be greater than today s DATE date This information is not used for DMERC 10706 ACUTE MANIF DTP The segment providing the acute manifestation for this line
65. information is not used for DMERC 10835 ORD PROV ZIP N403 The ordering provider s zip code is missing for this line CODE When reporting address information the city state and zip MISSING code information must be included This information is not used for DMERC 10836 CANNOT SEND REF The segment containing additional ordering provider gt 5 ORD PROV Identification information exceeds maximum use When this 2ND ID information is reported only 5 occurrences per line may be SEGMENTS used 10837 ORD PROV REF01 The qualifier for the ordering provider s secondary REF ID identification number information for this line is invalid QUALIFER Qualifier used to indicate the identification number INVALID Valid Values OB State license number 1B Blue Shield provider number 1C Medicare provider number 1D Medicaid provider number 1G Provider UPIN number 1H CHAMPUS identification number El Employer s Identification Number G2 Provider commercial number LU Location number N5 Provider plan network identification number SY Social Security Number this may not be used for Medicare X5 State industrial accident provider number 10838 ORD PROV REF02 Ordering provider s secondary identification number UPIN UPIN MISSING is missing for this line Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 153 Edit Edit Description Element Edit Explanation Number Segment ID
66. line pricing repricing savings PRICING amount information is invalid If reported this amount cannot CANNOT HAVE exceed two positions to the right of the decimal point gt 2 DEC This information is not used by DMERC 11023 PRICING RATE HCP05 The value entered as the line pricing repricing rate EXCEEDS information is invalid If reported this amount cannot exceed MAXIMUM 9 positions This information is not used by DMERC 11024 PRICING RATE HCP05 The value entered as the line pricing repricing rate CANNOT HAVE information is invalid If reported this amount cannot exceed gt 2 DEC two positions to the right of the decimal point PLACES This information is not used by DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 179 Edit Edit Description Element Edit Explanation Number Segment ID 11025 APPR APG HCPO07 The amount entered as the approved APG amount is AMT PRICING invalid If reported this amount cannot exceed 18 positions EXCEEDS MAXIMUM This information is not used by DMERC 11026 APPR APG HCPO07 The amount entered as the approved APG amount is AMT PRICING invalid If reported this amount cannot exceed two positions CANNOT HAVE to the right of the decimal point gt 2 DEC This information is not used by DMERC 11027 VALUE HCP12 The value entered as the pricing repricing approved units or EXCEEDS inpatient days is invalid If reported this amount
67. maximum use When this information SEGMENT EXC is reported only 1 occurrence per transaction may be used MAX USE This information is not used for DMERC 10135 PAYER ADR N3 The segment providing the payer address for this claim SEGMENT EXC exceeds maximum use When this information is reported MAX USE only 1 occurrence per transaction may be used This information is not used for DMERC 10136 PAYER CITY N401 The payer city is missing for this claim When reporting MISSING address information the city state and zip code information must be included This information is not used for DMERC 10137 PAYER STATE N402 The payer state abbreviation is missing for this transaction ABR MISSING When reporting address information the city state and zip code information must be included This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 27 Edit Edit Description Element Edit Explanation Number Segment ID 10138 PAYER ZIP N403 The payer zip code is missing for this transaction When CODE reporting address information the city state and zip code MISSING information must be included This information is not used for DMERC 10139 ADD PAYER ID REF The segment containing additional payer identification SEGMENT EXC information exceeds maximum use When this information is MAX USE reported only 3 occurrences per transaction may be used This i
68. may download an Electronic Report Package Included in the reports package is the Received Claims Listing report which will identify the claims that were accepted into our system for processing by assigning each claim a Claim Control Number CCN If claims were rejected an Error Listing report will also be included in the reports package The Error Listing report will identify which claims contained errors due to a lack of or an error in critical information transmitted Rejected claims may then be corrected and retransmitted with minimal impact on reimbursement time Reduces costs Transmitting electronically reduces the need for paper claim forms Postage and handling costs will also be reduced since you will not have to mail your claim In addition billing electronically results in more efficient use of office staff by freeing up time spent manually processing claims and transactions 24 hour claim transmission Billing electronically allows you to transmit claims 24 hours a day You are not bound by daily mail pick ups unnecessary trips to the post office or holiday and weekend mail restrictions Additionally you are able to select the time you want to transmit your claims based around your schedule Automatic transferring to other DMERCs Paper claims must be mailed to the appropriate DMERC and will be returned by mail if they are received by another DMERC Whereas if a claim is transmitted electronically for a beneficiary who resides in a
69. missing for this transaction CODE When reporting address information the city state and zip MISSING code information must be included This information is not used for DMERC 10090 ADD PAYTO REF The segment containing additional pay to provider PROV ID identification information exceeds maximum use When this SEGMENT EXC information is reported only 5 occurrences per transaction MAX USE may be used This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 19 Edit Number Edit Description Element Segment ID Edit Explanation 10091 PAYTO PROV ID 2 QUAL INVALID REFO1 The qualifier for the pay to provider secondary identification number information for this transaction is invalid Valid Values OB State license number 1A Blue Cross provider number 1B Blue Shield provider number 1C Medicare provider number 1D Medicaid provider number 1G Provider UPIN number 1H CHAMPUS identification number J Facility ID number B3 Preferred Provider Organization number BQ Health Maintenance Organization number El Employer s Identification Number FH Clinic number G2 Provider commercial number G5 Provider site number LU Location number SY Social Security Number this may not be used for Medicare U3 Unique Supplier Identification Number USIN X5 State industrial accident provider number This informati
70. not used for DMERC 10557 REF ID REFO1 The qualifier for the other payer rendering provider QUALIFIER secondary identification number information for this claim is INVALID invalid This information is used when a payer is submitting this claim to another payer and should not be submitted by the supplier Valid Values 1B Blue Shield provider number 1C Medicare provider number El Employer s Identification Number G2 Provider commercial number LU Location number N5 Provider plan network identification number This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 105 Edit Edit Description Element Edit Explanation Number Segment ID 10558 OTH PAY REF02 The other payer rendering provider secondary identification REND PROV ID number is missing for this claim MISSING This information is used when a payer is submitting this claim to another payer and should not be submitted by the supplier This information is not used for DMERC 10559 OTH PAY PUR NM1 The segment providing the other payer purchased service SER PRO SEC provider name information for this claim exceeds maximum EXC MAX USE use When this information is reported only 1 occurrence per claim may be used This information is used when a payer is submitting this claim to another payer and should not be submitted by the supplier This information is not used for DMERC 105
71. of Files DATA TYPE SEND_ANSITEST List file names MAILBOX SD_CATI INBOUND View a file PROTOCOL PROMPT Upload Put a file in Mailbox FILE TYPE STREAM Display Activity Log PRINTER_PAUSE INITIAL MENU OPT Return to main menu zek Network A ERE ENTER YOUR SELECTION 1 2 The Data Type Value menu will appear To select a data type type the corresponding number and press Enter Choose a Data Type Value SEND_PRODNSF RECE I VE_ERL RECEIVE _NSFERN SEND_ANSI RECEIVE_ANSI RECEIVE _ACK SEND_ANSITEST RECEIVE_ANSITEST CANIM UN 99 Return to Main Menu ENTER SELECTION NO CARRIER 3 To return to the Mailbox Access Facility menu type 99 and press Enter Region D DMERC EDI Manual Revised June 2002 Stratus Network User Guide Page 13 Description of the data types 1 SEND_PRODNSF Select this option to send a production file in the National Standard Format Note if you have been approved to send ANSI production files you must select option 4 SEND_ANSICLAIM 2 RECEIVE_ERL Select this option to download Electronic Report Packages 3 RECEIVE_NSFERN Select this option to download Electronic Remittance Notices in the National Standard Format 6 RECEIVE_ACK Select this option to download 997 Functional Acknowledgement reports 7 SEND_ANSITEST Select this option to send a test 837 transaction in the ANSI 4010 format 8 RECEIVE_ANSITEST Select this option to download your phase II
72. of non assigned claims that were accepted rejected and transferred in relation to the total number of non assigned claims received The total dollar amount of non assigned claims received accepted rejected and transferred The percentage in dollar amount of non assigned claims accepted rejected transferred as that dollar amount relates to the dollar amount of received non assigned claims Region D DMERC EDI Manual November 2001 CARRIER 05655 CIGNA INC RUN DATE 09 09 01 PROGRAM X8371600 MEDICARE DMERC RUN TIME 6 48 32 REPORT 716004 SUBMISSION SUMMARY PAGE 1 SUBMITTER ID NAME D08601212 ANY BILLING COMPANY BILLING ID PAY TOID 9999990001 9999990001 ASSIGNED CLAIMS NON ASSIGNED CLAIMS RECEIVED ACCEPTED REJECTED TRANSFER RECEIVED ACCEPTED REJECTED TRANSFER 100 0 000 0 000 0 000 0 000 0 000 0 50 00 50 00 00 00 00 200 00 00 B 100 0 000 0 000 0 000 0 000 0 000 0 These rows shows total number of claims shown on this report and lists amount and This column reports the number and This column reports the number and dollar amount of rejected Assigned dollar amount of accepted Non Assigned percent totals by type of claims received claims claims shown on this report and lists amount and percent totals by type of claims received dollar amount of transferred Assigned dollar amount of rejected Non Assigned claims claims This column reports the number and dollar amount of received Assigned clai
73. of product service code QUALIFIER used for this line is invalid INVALID Valid Value N4 National Drug Code in 5 4 2 format 11222 PROD SERVIC LINO3 The national drug code being reported in this segment is E ID MISSING missing When this segment is sent this is a required element 11223 2410 CTP CTP The segment providing the drug pricing information for this INVALID FOR line is invalid X12 VERSION This edit indicates an invalid format and should be resolved by contacting your software vendor This information is not used for DMERC 11224 DRUG UNIT CTP03 The drug unit price for this claim line is invalid When PRICE INVALID reported this element must contain a numeric value This information is not used for DMERC 11225 DRUG UNIT CTP03 The drug unit price for this claim line exceeds 18 positions PRICE EXCEED This information is not used for DMERC MAXIMUM 11226 DRUG UNIT CTP03 The drug unit price for this claim line exceeds two positions PRC CANNOT to the right of the decimal point HAVE gt 2 DEC PLACES This information is not used for DMERC 11227 DRUG CTP04 The national drug unit count amount submitted with this QUANTITY claim line is invalid When reported this element must INVALID contain a numeric value This information is not used for DMERC 11228 DRUG CTP04 The national drug unit count amount exceeds15 positions QUANTITY EXCEEDS This information is not used for DMERC MAXIMUM Region D DMERC EDI Manual Revised Ap
74. or HHMMSS or HHMMSSSS 10 Exclusion condition violated www cignamedicare com edi Page 26 Chapter Six Segment and Element AK404 Copy of Bad Data Element Transaction Set Acknowledg ement Code Transaction Set Syntax Error Code Element Description Copy of specific data that caused the error code in AK403 Code acknowledging the transaction set identified in the AK202 Code required if an error exists Region D DMERC EDI Manual November 2001 Valid Values with Description Accepted transaction was accepted and passed on to VMS for editing Accepted but errors were noted Rejected Message Authentication Code MAC failed Rejected transaction was rejected errors noted in AK3 and or AK4 need corrected and transaction needs to be resubmitted Rejected assurance failed validity test Rejected content after decryption could not be analyzed Transaction set not supported the submitted transaction is not supported by the receiver i e If someone sent us a 270 and we did not have it available or sent us a 271 which we would never receive Transaction set trailer missing transaction being acknowledged did not contain a SE segment Transaction set control number in header and trailer don t match SE02 must be identical to ST02 Number of included segments does not match actual count SEO1 does not equal the number of segments within the ST SE including both the SE and SE One or more segme
75. products and services available to improve your business productivity These include Claim Status Inquiry Electronic Remittance Notices and Beneficiary Eligibility The following pages provide a detailed explanation and the requirements for each EDI option Remember To apply for any of these options you must submit the DMERC EDI Customer Profile located in the Appendix of this manual Claim Status Inquiry CSI Claim Status Inquiry CSD allows you to electronically check the status of production claims after they have passed the front end edits and received Claim Control Numbers CCNs MCM 3023 2 Through CSI you will know if your claim has been paid denied or is still pending At least three working days after you successfully transmit an electronic claim you will be able to locate your claim in the processing cycle If you are checking the status of pending claims there are additional screens available which contain more detailed status information CSI is available for both electronic and paper claims Overview of CSI CSI is divided into the following two main functions e General claims information e Pending claims information General claims information The provider claims display screen provides the following information about electronic claims transmitted during the last 18 months e Paid or denied claims Note CSI does not display payment amounts for non assigned claims e Claims not paid due to full payment made by
76. representing the claim level adjusted amount EXCEEDS exceeds 18 positions MAXIMUM This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10946 ADJ AMOUNT CAS18 The value representing the claim level adjusted amount CANNOT HAVE exceeds two positions to the right of the decimal point gt 2 DEC PLACES This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10947 ADJUSTED CAS19 The value representing the claim level adjusted units of UNITS service exceeds 15 positions EXCEEDS MAXIMUM This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10948 ADJ UNITS CAS19 The value representing the claim level adjusted units of EXCEEDS MAX service exceeds the maximum number of positions to the DECIMAL right of the decimal point PLACES This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 169 Edit Edit Description Element Edit Explanation Number Segment ID 10949 COB PAYER AMT02 The va
77. representing the claim level total adjusted units of EXCEEDS MAX service exceeds the maximum number of positions to the DECIMAL right of the decimal point PLACES This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10929 ADJ AMOUNT CAS06 The value representing the claim level adjusted amount EXCEEDS exceeds 18 positions MAXIMUM This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10930 ADJ AMOUNT CAS06 The value representing the claim level adjusted amount CANNOT HAVE exceeds two positions to the right of the decimal point gt 2 DEC PLACES This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10931 ADJUSTED CAS07 The value representing the claim level adjusted units of UNITS service exceeds 15 positions EXCEEDS MAXIMUM This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10932 ADJ UNITS CAS08 The value representing the claim level adjusted units of EXCEEDS MAX service exceeds the maximum number of positions to the DECIMAL right of the decimal point PLACES This information is used
78. secondary identification number indicated on this SECONDARY ID claim for the purchased service provider for this line INVALID item is invalid If a Medicare provider number was reported it must be a valid supplier number assigned by the National Supplier Clearinghouse If a provider UPIN was reported it must be a valid UPIN Number This information is not used for DMERC 20133 SERVICE FACILITY N402 The state abbreviation indicated on this line item for LOCATION STATE the service facility or oxygen test facility state is not a INVALID valid two character state abbreviation code 20134 SERV FACILITY N403 The zip code indicated on this line item for the service LOCATION ZIP facility or oxygen test facility address was reported in CODE INVALID an invalid format Verify the zip code contains only numeric data and is not all zeros or all nines and is either five or nine digits in length 20135 LAB FACILITY N404 The country code indicated on this line item for the COUNTRY CODE service facility or oxygen test facility address is not a INVALID valid country code 20136 SERV FAC LOC REF REFO1 The qualifier for the service facility location or oxygen ID QUALIFIER test facility s secondary identification number INVALID information for this line item is invalid Valid Value 1C Medicare provider number 20137 SERV FAC LOC REF02 The secondary identification number indicated on this SECONDARY ID INVALID claim for the service facility or oxyg
79. segment providing the patient when other than the ADDRESS subscriber address for this claim is missing This SEGMENT information is required when reporting patient information MISSING when other than subscriber This information is not used for DMERC 11071 SERVICE N3 The segment providing the service facility address is FACILITY missing If the place of service is other than 12 home this ADDRESS information is required MISSING 11072 LINE ITEM V102 The value representing the line item charged amount CHG AMT exceeds 9 positions EXCEEDS MAXIMUM www cignamedicare com edi Revised April 2003 Page 186 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 11073 SVCLINE ITEM SV102 The value entered as the line item charge is invalid This CHG AMT amount cannot have greater than two positions to the right CANNOT HAVE of the decimal point gt 2 DEC 11074 CONTRACT CN103 The value representing the contract percentage amount is EXCEEDS MAX invalid If reported do not exceed the maximum number of DECIMAL positions to the right of the decimal point PLACES This information is not used for DMERC 11075 FRM FRM You have identified a CMN to be included with this claim SEGMENT line The FRM segment is a required segment for claim lines REQUIRED IF that indicate a CMN is attached CMN LOOP SENT 11076 CANNOT SEND CRC This line exceeds 3 occurrences of the seg
80. service code QUALIFIER used for this line is invalid INVALID Valid Values HC Health Care Financing Administration Common Procedural coding System Codes ZZ Mutually defined 11212 EMERGENCY SV109 The qualifier indicating emergency services for this line is INDICATOR invalid INVALID Valid Value Y Yes 11213 DTP ORDER DTP The segment providing the order date for this line is invalid DATE NOT ALLOWED IN This edit indicates an invalid format and should be resolved X12 VERS by contacting your software vendor This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 205 Edit Edit Description Element Edit Explanation Number Segment ID 11214 DTP DTP The segment providing the referral date for this line is REFERRAL invalid DATE NOT ALLOWED IN This edit indicates an invalid format and should be resolved X12 VER by contacting your software vendor This information is not used for DMERC 11215 QTY SEGMENT QTY The segment providing the anesthesia modifying units for NOT ALLOWED this line is invalid IN X12 VERSION This edit indicates an invalid format and should be resolved by contacting your software vendor This information is not used for DMERC 11216 MEASUREMEN MEA The qualifier identifying the test results or patient s height T QUALIFIER being reported for this line is invalid INVALID Valid Values GRA Gas test rate H
81. should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare This information is not used for DMERC 10862 PAYOR NAME MISSING NM103 The company name is missing for this line If the other payer prior authorization or referral number was identified as a non person entity this element must contain the company name This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare This information is not used for DMERC 10863 OTHER PAYER ID QUALIFIER INVALID NM108 The qualifier identifying the other payer prior authorization identification number for this line is invalid Valid Values PI Payer identification XV Health Care Financing Administration National Plan Id This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare This information is not used for DMERC 10864 CANNOT SEND gt 2 2420G REF SEGMENTS REF The segment containing the other payer prior authorization or referral number information exceeds maximum use When this information is reported only 2 occurrences per line may be used This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this cla
82. supplies billed were actually delivered by reviewing the source documents e Confirm that procedure and diagnosis codes are being used appropriately e Verify the compliance of assignment based claims This will be done by confirming there was a collection of deductible and coinsurance Once a review has been completed the results are presented to you and if applicable CIGNA Medicare will make suggestions for resolving any problems If major discrepancies are found you will be expected to refund any resulting overpayments and implement corrective actions to prevent future errors www cignamedicare com edi Chapter Four Testing All EMC submitters must test software compatibility in order to verify that claim data is transferred in the appropriate elements as designated by ANSI X12N version 4010 Upon receiving this manual you should have also received a submitter ID and any other applicable IDs Once you have received the necessary IDs for electronic billing and software you are ready to begin the testing process The testing process is divided into two different phases Phase I verifies that you have submitted in the correct format based on the ANSI X12N version 4010 837 format A 997 Functional Acknowledgment report will be generated to acknowledge the receipt of the file and also to indicate if you passed Phase I Phase II verifies that the information you have transmitted is accurate i e you have used valid HCPCS codes modifier
83. test results sent using Option 7 4 SEND_ANSI Select this option to send production transactions in the ANSI 4010 format 5 RECEIVE_ANSI Select this option to download transactions in the ANSI 4010 format www cignamedicare con edi Revised June 2002 Page 14 Chapter Five Mailbox Access Facility Menu Option 6 Upload Puta file in Mailbox This option would be used to upload ANSI test and production files 1 Make sure that the data type is Send_XXXX where XXXX represents the type of data to be sent in the Current Settings box If it is incorrect you will need to change the data type Please see page 12 of this chapter for information on changing data types 2 Type 6 to select Upload Put a file in Mailbox and press Enter tetttee tee eeeeeet Mailbox Access Facility t ttttteeaee User Id MBOO1A 0 Set User Defaults Current Settings 1 Change Data Type 2 Number of Files DATA TYPE SEND_ANSITEST 3 List file names MAILBOX SD_CATI INBOUND 4 View a file VRestaetestatantetatentatatent eta teh alae aoa PROTOCOL PROMPT 6 Upload Put a file in Mailbox FILE TYPE STREAM 7 Display Activity Log PRINTER_PAUSE NO INITIAL MENU OPT NONE 4 99 Return to main menu Network 7 ENTER YOUR SELECTION 6 3 If you have previously selected NONE for the protocol default you will be prompted to select a protoco
84. the CIGNA Medicare system This report will accompany the Electronic Receipt Listing ERL for DMERC only Claim Status Inquiry CSI A feature that allows providers suppliers to electronically check the status of production claims This allows EMC providers suppliers to electronically access information displaying the receipt and payment status of their pending or assigned claims Claim File Once claim data is entered into your Medicare billing software the billing software then compiles the data and develops an electronic file in the ANSI format This file is then transmitted electronically to CIGNA Medicare Clean Claim A claim that does not require investigation or development outside the Medicare operation on a prepayment basis www cignamedicare com edi G 2 Glossary Clearinghouse An entity that transfers or moves EDI transactions for a provider supplier A clearinghouse accepts multiple types of claims and sends them to various payers including Medicare Note You are responsible for verifying that claims are being transmitted electronically and for the accuracy of claims that a billing service or clearinghouse sends to CIGNA Medicare on your behalf Code Set A group of codes with pre defined meanings A code set may be controlled by X12 or by an independent industry group Only values from a named code set may be used in specific data elements Communications Software The software that enables one to send or receive inform
85. the DMERC EDI Department 20158 CLAIM RECEIPT DTPO3 The date entered as the claim date of receipt was DATE INVALID entered in an invalid format Verify the date is a valid calendar date and not a date greater than today s date If you receive this edit contact the DMERC EDI Department 20159 CLAIM SOURCE REF The segment containing the claim source code INVALID segment is missing If you receive this edit contact the DMERC EDI Department 20160 CLAIM SOURCE REF REFO1 The code indicating the claim source code is invalid ID QUALIFIER INVALID Valid Value PR Payer If you receive this edit contact the DMERC EDI Department 20161 CLAIM SOURCE REF02 The value used to indicate the type of claim submitted CODE INVALID is invalid Valid Value E EMC Region D DMERC EDI Manual Revised April 2003 Front End Edits Medicare Page 27 Edit Number EDIT DESCRIPTION ElementID Edit Explanation 20162 OTH PAYER NM103 The other payer s patient s last name was entered in an PATIENT LAST invalid format Verify the first position of the other NAME INVALID payer s patient s last name is not a space and only contains alpha characters This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare This information is used for Medigap secondary to Medicare claims and should not be submitte
86. the beneficiary rented the item or if the beneficiary purchased at initial issuance If still cannot be resolved call the Public Relations Department in Boise www cignamedicare com edi CARRIER 05655 CIGNA INC RUN DATE 09 09 01 PROGRAM X8371600 MEDICARE DMERC RUN TIME 6 48 32 REPORT 716006 CMN REJECT LISTING PAGE 1 BILLER SUBMITTER ID D08601212 SUPPLIER PAY TO 1D 9999990001 a P Ka a a Js R HICN CCN PROC CODE ORIGINAL SUBMIT TYPE RECERT LENGTH M ERROR CODES INITIAL INITIAL REVISED OF DATE DATE DATE NEED 999999999D 01252810001000 KOOO1RR 01212000 01212000 RECER 05212001 99 02 03 3048 CANNOT RCT REV DISC CMN AE TOTAL CMNS REJECTED 0000001 CMN Type Initial INIT Recertification RECER Revision REV CMN Edit Number Refer to Chapters 7 8 and 9 for edit explanations i Procedure Code sent in for this CMN Form number reported for this line Initial date on file for this CMN as Recertification Revision Date Total number of CMN s rejected for all transactions on file at the DMERC submitted with this CMN received on this date as shown on this report C Initial date reported for this CMN on the submitted line Chapter Seven Front End Edits Introduction Front end edits are broken down into three categories or levels It is important to understand the differences between these levels to determine error resolution In addition to Medicare specific and DMERC specific edits CMS has requir
87. the report is useful if you are familiar with an ANSI file It shows the loop segment and element information in which the error occurred This will be useful if you have to contact your software vendor to request assistance in resolving a particular edit Region D DMERC EDI Manual November 2001 CARRIER 05655 CIGNA INC RUN DATE 08 16 01 PROGRAM X8371600 MEDICARE DM ERC RUN TIME 14 45 05 REPORT 716003 CL LEVEL ERROR LISTING PAGE 1 SUBMITTER ID NAME D0869999 ANY BILLING COMPANY BILLING ID NAME 9999990001 SUPPLIER COM PANY PAY TO ID NAME SAME AS BILLING BENEFICIARY ID NAME 222200011B REJECTED TEST PATIENT ID NAME 222200011B REJECTED TEST Eee PATIENT ACCOUNT NO TOTAL EARLIEST LATEST TOTAL SEQ LINES FROM DATE TO DATE BILLED AMT 0001 TEST2222001 0001 03252001 03252001 2000 00 Ese LOOP LOOP SEQ SEG SEG SEQ VERSION DATA ELEMENT NUMBER AND NAME 110199 RELATED CAUSE 2 CODE INVALID 2300 0001 CLM 0001 A 11 2 RELATED CAUSES CODE 2 23 Ge 10203 SPEC PROG IND INVALID 2300 0001 12 SPECIAL PROGRAM INDICATOR O E Ae Sequence of claim that received the rejection out of all claims received for this Run Date Total number of lines on this claim Loop containing the data that received this edit edit submitted containing the data that received this edit Edit version number assigned by claims processing system Originally submitted data that caused this Segment sequence within the loop Edit number Refer to Chapters 7
88. the same regardless of the software These instructions are given with the assumption that your software is not scripted If you are not sure whether your software is scripted contact your software vendor If your software is scripted your process may not follow our instructions In this case your software vendor should instruct you on how to send your files Helpful Information Submittal Times for Claims Claims are received into the Stratus Network minutes after transmission After being received claim files are held in the user s mailbox until the Stratus Network downloads your claim file s and transmits it to CIGNA Medicare The Stratus Network will sweep your mailbox several times a day see chart below However 5 00 p m Eastern Standard Time is the cutoff time for that business day s production files Anything that is collected from the Stratus Network after 5 00 p m will contain the next business day as the date CIGNA Medicare received your claim file This will be reflected in the Julian date included in the Claim Control Number www cignamedicare con edi Page 2 Chapter Five Customer Support Center If you have a Stratus Network password reset or inactive user ID support issue contact the Customer Support Center s Electronic Commerce Helpdesk at 1 800 810 3388 This service is available 7 days a week 24 hours a day Please have the following information available e Logon ID MB e Submitter ID alpha char
89. then this error would occur l e if CLM was not present Loop occurs over maximum times for those loops that repeat and a max is assigned if one was exceeded this error would be generated l e If there were 101 CLM segments signifying 101 2300 Loops this rejection would occur Segment exceeds maximum use within a loop if the segment repeats more than standard allows l e 16 DTP s in the 2400 loop would cause this rejection since only 15 are allowed Segment not in defined transaction set If a valid X12 segment was used in this transaction however it was not named for this transaction then this error would occur l e TS3 is a valid segment for the 835 if sent in a 837 it would reject with this error Segment not in proper sequence segment positions are defined by the X12 standard if they come in out of order this error would occur l e CRC pos 220 comes before DTP pos 135 in the 2300 loop would cause this error Segment has data element errors If any of the elements have errors this error will show and be followed by an AK4 segment Position in Composite element if segment referencing a composite in the incoming file AK401 1 Element Position of element in error in Position in the segment identified in AK3 Segment l e the number 9 here with a AK301 of NM1 would be the identifier in NM109 Region D DMERC EDI Manual November 2001 Page 8 Chapter Six Segment Element and Name Element AK4
90. today s date This information is not used for DMERC 10221 DT LAST SEEN DTP The segment providing the date last seen for this claim SEG EXC MAX exceeds maximum use If this information is reported only 1 USE occurrence per claim may be used This information is not used for DMERC 10222 NOT USED 10223 DT LAST SEEN DTP02 The qualifier indicating the format used to report the date FMT Q INVALID last seen for this claim is invalid Valid Value D8 Date expressed in format CCYYMMDD This information is not used for DMERC 10224 DT LAST SEEN DTPO3 The date last seen entered is invalid for this claim When INVALID FMT entered this information must be entered in a valid CCYYMMDD format This information is not used for DMERC 10225 DT LAST SEEN DTPO3 The date last seen entered is invalid for this claim When FUTURE DT entered this information must not be greater than today s date This information is not used for DMERC 10226 CURRENT ILL DTP The segment providing the onset of current illness symptom DT SEG EXC for this claim exceeds maximum use If this information is MAX USE reported only 1 occurrence per claim may be used This information is not used for DMERC 10227 NOT USED 10228 CURRENT ILL DTP02 The qualifier indicating the format used to report the onset of DT FMT Q current illness or symptom date for this claim is invalid INVALID Valid Value D8 Date expressed in format CCYYMMDD This information is not used f
91. type of ambulance CODE INVALID transportation for this line is invalid Valid Values Initial trip R Return trip T Transfer trip X Round trip This information is not used for DMERC 10603 AMBU TRANS CR104 The code used to indicate the reason for the ambulance REASON transport for this line is invalid INVALID Valid Values A Patient was transported to nearest facility for care of symptoms complaints or both B Patient was transported for the benefit of a preferred physician C Patient was transported for the nearness of family members D Patient was transported for the care of a specialist or for availability of specialized equipment E Patient transferred to rehabilitation facility This information is not used for DMERC 10604 UNIT BASIS CR105 The unit of measurement to indicate the distance the MEASURE ambulance traveled for this line is invalid INVALID Valid Value DH Miles This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 116 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10605 ROUND TRIP CR109 This element is used to provide narrative information to PUR MISSING indicate the purpose of the round trip ambulance service for this line This is a required element if the ambulance transport was a round trip This information is not used for DMERC 10606 TREATMNT CR201 The element containing the
92. use SEGMENT EXC When this information is reported only 1 occurrence per MAX USE transaction may be used This information is not used for DMERC 10063 BILL PROV N3 The segment providing the billing provider s address for this ADR transaction exceeds maximum use When this information is SEGMENT EXC reported only 1 occurrence per transaction may be used MAX USE 10064 BILL PROV N4 The segment providing city state and zip code information C S Z for the billing provider for this transaction is missing When SEGMENT reporting address information the city state and zip code MISSING information must be included Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 15 Edit Edit Description Element Edit Explanation Number Segment ID 10065 BILL PROV N401 The billing provider s city is missing for this transaction CITY MISSING When reporting address information the city state and zip code information must be included 10066 BILL PROV N402 The billing provider s state abbreviation is missing for this STATE ABR transaction When reporting address information the city MISSING state and zip code information must be included 10067 BILL PROV ZIP N403 The billing provider s zip code is missing for this transaction CODE When reporting address information the city state and zip MISSING code information must be included 10068 ADD BILL REF The segment containing additional
93. used for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 119 Edit Number Edit Description Element Segment ID Edit Explanation 10613 XRAY AVAIL IND INVALID CR212 The qualifier indicating the X ray availability for spinal manipulations is invalid for this line Valid Values N No X rays are not maintained and available for carrier review Y Yes X rays are maintained and available for carrier review This information is not used for DMERC 10614 CERT TYPE CODE INVALID CR301 The qualifier indicating the DMERC certification type is invalid for this line This information is required on all DMERC claims requiring CMN s with the exception of CMN Form 484 2 Valid Values Initial R Renewal Recertification S Revised 10615 DURATION QUALIFIER INVALID CR302 The measurement qualifier for the CMN length of need is invalid for this line This information is required on all DMERC claims requiring CMN s with the exception of CMN Form 484 2 Valid Value MO Months 10616 CERT TYPE CODE INVALID CR501 The qualifier indicating the oxygen certification type for CMN Form 484 2 is invalid for this line This information is required on all DMERC claims requiring a CMN Form 484 2 Valid Values Initial R Renewal Recertification S Revised 10617 LENG MED NECESS MISSING CR502
94. value n 4 To select your default protocol type the character that corresponds to your selection i e type Z for ZMODEM and press Enter 5 To return to the Mailbox Access Facility menu type 99 and press Enter Note The EDI Department recommends using Z modem to send and receive files for the following reasons e 7Z modem is not as susceptible to altering a transmission due to line noise in your communication line e Z modem is a faster protocol and is more effective at sending files at speeds greater than 4800 bps e 7Z modem allows better error detection than other protocols The protocol setting on this screen must match the protocol setting within your software For software settings refer to the user guide for your communications software If you select NONE as your protocol you will be prompted each time you transmit to select your protocol www cignamedicare con edi Revised June 2002 Page 12 Chapter Five Mailbox Access Facility Menu Option 1 Change Data Type This option allows you to select the type of transaction you wish to send or receive Before changing the data type look at the Current Settings box to see what data type is currently selected To change your data type 1 At the Mailbox Access Facility menu type 1 and press Enter KACESEREEECEEAKE OH Mailbox Access Facility Kekkkkkkkekkkeeeeeee User Id MBOO1A Set User Defaults Current Settings Change Data Type Number
95. was medically necessary 60 Transportation was to the nearest facility This information is not used for DMERC 10631 HOSPICE EMP CRC The segment containing hospice employee information IND EXC MAX exceeds maximum use If this information is reported only 1 USE occurrences per claim may be used This information is not used for DMERC 10632 NOT USED 10633 HOSPICE EMP CRCO2 The qualifier indicating the provider is employed by a PROV IND hospice is invalid for this line INVALID Valid Values N No Y Yes This information is not used for DMERC 10634 COND IND CRC03 The code indicating the provider is a hospice employee is INVALID invalid for this claim Valid Value 65 Open This information is not used for DMERC 10635 DMERC COND CRC The segment containing general DMERC CMN information IND EXC MAX exceeds maximum use If this information is reported only 2 USE occurrences per claim may be used 10636 NOT USED 10637 CERT COND CRC02 The DMERC certification condition code indicator is invalid IND INVALID for this line Valid Values N No Y Yes www cignamedicare com edi Revised April 2003 Page 124 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10638 COND CODE CRCO03 The code indicating the patient s condition is invalid for this INVALID line Use values 37 AL and P1 for CMN form 484 2 and 38 for all DMERC CMN s including CMN form 484 2 Valid Value
96. your password Once you change the initial password CIGNA Medicare is not able to verify your password Password hints Your password must contain 5 8 characters The password is case sensitive which means it must be entered in the same upper and lowercase combination each time In addition the password cannot contain the same character consecutively i e happy would be invalid because of the repeating P s For security reasons your password will not show on the screen when typed You have dialed into CIGNA s gateway service Center Please type login followed by your user id and then press the return key login MBOO1A Password The following list describes the password change mask The letter in the string describes the type of character that must be entered for the new password Yo gt aeiou gt bedfghjklmnpqrstvwxyz gt any character gt 1234567890 gt abedefghijklmnopqrstuvwxyz gt space character 3 gt WNTHS8ET tt 25 lt gt 2 INN C1 de L gt a z 0 9 XXXXXXXXXXXXXXXX Enter a new password www cignamedicare con edi Revised June 2002 Page 8 Chapter Five Note The Centers for Medicare and Medicaid Services CMS requires all passwords to be secure and changed at periodic intervals This is to ensure the security of all electronic data interchange EDI transactions and data You will be prompted to change the password every 60 days and cannot be any of the past three passwords us
97. 003 Page 90 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10499 PAT SIG O104 The code identifying the source of the other insurance SOURCE patient s signature is invalid for this claim INVALID This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare This information is used for Medigap secondary to Medicare claims and should not be submitted unless there is an approved Medigap policy held by this subscriber Valid Values B Signed signature authorization form or forms for both HCFA 1500 Claim Form block 12 and block 13 are on file C Signed HCFA 1500 Claim Form on file M Signed signature authorization form for HCFA 1500 Claim Form block 13 on file P Signature generated by provider because the patient was not physically present for services S Signed signature authorization form for HCFA 1500 Claim Form block 12 on file Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 91 Edit Number Edit Description Element Segment ID Edit Explanation 10500 REL INFO CODE INVALID Ol06 The code specifying the type of release of information the patient has issued for the other insurance is invalid for this claim This information is used for Medicare Secondary Payer claims and should not be submitted unle
98. 003 Page 60 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10363 CHIRO CR205 The qualifier indicating the length of time chiropractic TREATMNT treatment has been administered is invalid for this claim TIME Q INVALID Valid Values DA Days MO Months WK Week YR Years This information is not used for DMERC 10364 TREATMENT CR207 The value representing the number of chiropractic NUMBER IN treatments rendered in the month for which this claim is MONTH being billed is missing MISSING This information is not used for DMERC 10365 CHIRO PAT CR208 The patient s condition code indicating the need for spinal COND CODE manipulation is invalid for this claim INVALID Valid Values A Acute condition C Chronic condition D Non acute E Non life threatening F Routine G Symptomatic M Acute manifestation of a chronic condition This information is not used for DMERC 10366 CHIRO COMPL CR209 The value representing spinal manipulation complications is CODE INVALID invalid for this claim Valid Values N No Y Yes This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 61 Edit Edit Description Element Edit Explanation Number Segment ID 10367 CHIRO X RAY CR212 The qualifier indicating the X ray availability for spinal CODE INVALID manipulations is invalid for this claim
99. 0046 OXYGEN DTP The segment containing the oxygen saturation arterial blood SATURATION ABG gas test date is missing If an oxygen certification form is TEST DATE being sent with this claim this is a required segment MISSING 40047 MEASUREMENTS MEA The segment containing the results of the oxygen saturation INVALID arterial blood gas test question 7 on the oxygen certification form is missing or invalid You have indicated greater than 4 LPM is being prescribed and the test results were not provided 40048 PATIENTS MEA03 The subscriber s height was entered in an invalid format HEIGHT INVALID Verify the height was entered using numeric data only 40049 FORM 484 MEA03 The response to question 7A on the oxygen certification form QUESTION 7A was entered in an invalid format Verify the response is equal INVALID to spaces zeros or is numeric www cignamedicare com edi Revised April 2003 Page 6 Front End Edits DMERC Edit EDIT Element Edit Explanation Number DESCRIPTION ID 40050 FORM 484 MEA03 The response to question 7B on the oxygen certification form QUESTION 7B was entered in an invalid format Verify the response is equal INVALID to spaces zeros or is numeric 40051 OXYGEN FLOW REF The segment containing the oxygen flow rate information is RATE MISSING missing If an oxygen certification form is being sent with this claim this is a required segment 40052 NOTE MI
100. 01 Early amp Periodic Screening Diagnosis and Treatment or Child Health Assessment Program 02 Physically Handicapped Children s Program 03 Special Federal Funding 05 Disability 07 Induced abortion danger to life 08 Induced abortion rape or incest 09 Second opinion or surgery This information is not used for DMERC 10204 NON PAR PAR CLM16 The code indicating a non participating provider has an AGMNT CODE agreement to submit this claim as participating is invalid INVALID Valid Value P Participation Agreement This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 39 Edit Edit Description Element Edit Explanation Number Segment ID 10205 CLAIM DELAY CLM20 The code indicating the reason for a delay in filing this claim REASON is invalid CODE INVALID Valid Values 1 Proof of eligibility unknown or unavailable 2 Litigation 3 Authorization delays 4 Delay in certifying provider 5 Delay in supplying billing forms 6 Delay in delivery of custom made appliances 7 Third party processing delay 8 Delay in eligibility determination 9 Original claim rejected or denied due to a reason unrelated to the billing limitation rules 10 Administration delay in the prior approval process 11 Other This information is not used for DMERC 10206 ORDER DATE DTP The segment providing the order date for this claim exceeds SEGME
101. 01 2 Composite Identifies position within Data composite in the element Element identified in AK401 1 Position in Composite Element Description Valid Values with Description Data Data element number 3rd Element column in IG Reference Number Data Error code for identified Mandatory data element missing X12 Element element defined mandatory element was not Syntax included not IG Required just X12 Code mandatory See Attributes in 837 Implementation Guide Conditional required data element missing X12 defined conditional element not included Not IG relational X12 relational attribute of X if element comes as X attribute must contain pair Too many data elements number of allowed elements for the identified segment were exceeded most likely too many s Data element too short element does not meet the minimum length requirement Data element too long element exceeds maximum length restriction Invalid character in data element characters restricted based on attribute Used invalid character in this element l e used alpha character in a NO type element Invalid code value code or qualifier used does not appear on the X12 list of valid qualifiers for this element X12 code sets not IG code sets Invalid date entered future date invalid date l e 2 30 2001 or not in the correct format D8 CCYYMMDD or RD8 CCYYMMDD CCYYMMDD Invalid time entered invalid time 261315 or not in correct format HHMM
102. 01 X 004010X098 ST 837 000000001 ee KL A AK2 837 0002 AKS A AK9 A 000001 000001 000001 SE 0000000006 000000001 GE 1 000000001 IEA 1 000000001 a ISA06 997 Sender Identification Number te ISA08 997 Receiver Identification Number ISA09 997 Creation Date ISA13 Interchange Control Number Assigned by CIGNA Medicare for this 997 A ISA15 997 Test Production Indicator Element Separator Used to separate elements within a segment ISA16 Sub Element Separator Used to separate components in a sub element donaa the end of a segment o eooo mf akso w farson o fo ason P assos a asos o Electronic Reports Page 5 The 997 report will validate the basic format and sequencing of the file It is broken down into segments which report specific information within the submitted transaction as follows This segment identifies the type of transaction being acknowledged For example if a claim file was being submitted the AK1 and AK2 will notify the user that this 997 report is acknowledging an 837 transaction This segment identifies the transaction set control number on the original submitted file This is a unique number assigned to each transaction submitted and will have a one to one correlation to the original submitted transaction This segment reports errors with segments in the originally submitted transaction This segment will provide the segment information including segment ID and position wi
103. 1 The qualifier identifying the type of diagnosis code being QUAL INVALID sent first with this claim is invalid Valid Value BK Principal diagnosis ICD 9 codes Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 67 Edit Edit Description Element Edit Explanation Number Segment ID 10390 DIAG CODE 2 HI02 1 The qualifier identifying the type of diagnosis code being QUAL INVALID sent second with this claim is invalid Valid Value BF Diagnosis ICD 9 codes 10391 DIAG CODE 3 HI03 1 The qualifier identifying the type of diagnosis code being QUAL INVALID sent third with this claim is invalid Valid Value BF Diagnosis ICD 9 codes 10392 DIAG CODE 4 HI04 1 The qualifier identifying the type of diagnosis code being QUAL INVALID sent fourth with this claim is invalid Valid Value BF Diagnosis ICD 9 codes 10393 DIAG CODE 5 HIO5 1 The qualifier identifying the type of diagnosis code being QUAL INVALID sent fifth with this claim is invalid Valid Value BF Diagnosis ICD 9 codes This information is not used for DMERC 10394 DIAG CODE 6 HIO6 1 The qualifier identifying the type of diagnosis code being QUAL INVALID sent sixth with this claim is invalid Valid Value BF Diagnosis ICD 9 codes This information is not used for DMERC 10395 DIAG CODE 7 HIO7 1 The qualifier identifying the type of diagnosis code being QUAL INVALID sent seventh with this claim is
104. 10480 NOT USED 10481 COB AMT The segment providing the amount the other payer DISCOIUNT discounted exceeds maximum use If this information is AMT EXC MAX reported only 1 occurrence per claim may be used USE This information is used when a payer is submitting this claim to another payer and should not be submitted by the supplier 10482 NOT USED 10483 COB DAILY AMT The segment providing the daily limit amount for the other LMT AMT EXC payer exceeds maximum use If this information is reported MAX USE only 1 occurrence per claim may be used This information is used when a payer is submitting this claim to another payer and should not be submitted by the supplier 10484 NOT USED 10485 COB PAT PD AMT The segment providing the amount paid by the other payer AMT EXC MAX to the patient exceeds maximum use If this information is USE reported only 1 occurrence per claim may be used This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10486 NOT USED Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 87 Edit Edit Description Element Edit Explanation Number Segment ID 10487 COB TAX AMT AMT The segment providing the other payer tax exceeds EXC MAX USE maximum use If this information is reported only 1 occurrence per claim may be used This information is not used fo
105. 10971 HCPCS PAY MOA02 The value representing the payable amount for this HCPCS AMT EXCEEDS code exceeds 18 positions MAXIMUM This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10972 HCPCS PAY MOA02 The value representing the payable amount for this HCPCS AMT CANNOT code exceeds two positions to the right of the decimal point HAVE gt 2 DEC This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10973 ESRD PD AMT MOA08 The value representing the end stage renal disease EXCEEDS payment amount exceeds 18 positions MAXIMUM This information is not used for DMERC 10974 ESRD PD AMT MOA08 The value representing the end stage renal disease CANNOT HAVE payment amount exceeds two positions to the right of the gt 2 DEC decimal point This information is not used for DMERC 10975 PROF MOA09 The value representing the non payable professional COMPONENT component billed amount exceeds 18 positions AMT EXCEEDS MAXIMUM This information is not used for DMERC 10976 PROF MOA09 The value representing the non payable professional COMPONENT component billed amount exceeds two positions to the right AMT CANNOT of the decimal point HAVE gt 2 DEC This information is not used for DMERC 10977 SVC UNIT SV104 The value
106. 11201 DME PURCH SV505 The value representing the DME purchase price reported PRICE exceeds 18 positions EXCEEDS MAXIMUM This information is not used for DMERC 11202 DME PURCH SV505 The value representing the DME purchase price reported PRC CANNOT exceeds two positions to the right of the decimal point HAVE gt 2 DEC PLACES This information is not used for DMERC 11203 DME RENTAL SV506 The qualifier used to indicate the rental unit price indicator FREQUENCY for this line is invalid CODE INVALID Valid Values 1 Weekly 4 Monthly 6 Daily This information is not used for DMERC 11205 FIRST NAME NM104 The first name of the Purchased Service Provider is missing REQ IF PRCH for this claim If you have specified the Purchased Service SER PRV IS Provider to be a person this element must contain the first PERSON name of that person If the Purchases Service Provider was identified as a non person entity this element is not used This information is not used for DMERC 11206 PAYOR NM103 You have included the other payer s referring provider last LAST ORG name or organization name with this claim This information NAME NOT is invalid for this claim USED IN X12 VERS This edit indicates an invalid format and should be resolved by contacting your software vendor This information is not used for DMERC 11207 PAYOR NM103 You have included the other payer s rendering provider last LAST ORG name or organization name with this claim This information
107. 2 Viewing a File ec Jacecss eenean ae EEEE TA EEI TEE SEEE 24 Reti OG samera a E A R E EOE sient 26 Exit or Logoff riei ee E A E E E D E E a EE 28 Chapter Six Electronic RepOrtsiiss se iersenessestives rune senineerae GesectarereseMeaae se 1 Online Receipt VEMGAUOM csccanaisnroencoandensauet ences hia me eateinansevd nninecaundin eupvanstodencibaenines 1 Functional Acknowledgment noniine hile ieee al nia areca 2 Electronic Report Packages cccivavovis enrenar eiar aerate SEERE ESAEREN ERKENE 14 Chapter Seven Front End EGS ii sacscse arches acicerastrieniys ation niaeaate Deletes daatieaae ean 1 General Guideline Si reai E A a aes 2 Implementation Guide Edit Numbers 10001 10099 senai paa ean a e ents a a E Leake 5 10100 10199 iiinis seana e A EON R E 22 1020010299 eaae Aaa AP EE aA ETE E 38 www cignamedicare com edi Revised April 2003 Chapter Seven Front End Edits continued 10300 10509 itaup siete creer a udaeeatian cabins dacs ais 50 MOA VOSS sa ea a SA oa se A ed eA aah ae 69 NOBUO O59 sa coe ea alee ts cant a elena abe odes aa 91 POG OOS 06992 szin iee ae santa can e panes av eee ssa yaaa abe ee 115 DOPOD TOL sro sa ea ue ileus ak leh Tce a dal alee 132 10800 10899 sirere ai aee ie ae EEEE RETE ee 147 10900 10999 amenar a a aE 163 11000 11099 ts anina e E E tase eat leek dows 175 1110020199 aa eae anaes A A S 188 11200 11259 p rare e n a N ee Ee 202 Chapter Eight Front End Edits Medicare
108. 272 toll free for questions regarding e Action codes e EMC claim edits e Verification of claim information e Biller Purged Claim Reports e How a claim was processed paid or denied e Electronic Funds Transfer EFT e Error messages rejections Call the Customer Support Center s Electronic Commerce Helpdesk located in Bloomfield Connecticut at 800 810 3388 toll free for questions regarding e Stratus password and inactive user ID support Call the EDI Department located in Boise Idaho at 866 224 3094 toll free option 1 for questions about e Electronic reports e DMACS 837 e Transmission assistance and support e Testing electronic billing formats ANSI NSF e Getting started billing electronically e Beneficiary eligibility support e Electronic Remittance Notices ERNs e Claim Status Inquiry CSI support www cignamedicare com edi Revised April 2003 Page 2 Chapter Ten EDI Department cont e EDI Enrollment Form e Activation status e EDI application requests e Software or matrix requests e EDI application status e ID numbers and passwords e Name or address changes e ANSI 837 Approved Vendor List request Contact the Provider Education and Training PET Department located in Boise Idaho at 866 224 3094 toll free option 3 for questions regarding e Educational seminars Webinars and other educational outreach e Provider supplier training e Complex claim issues that have not been resolved through nor
109. 37 AL and P1 for CMN form 484 2 and 38 for all DMERC CMN s including CMN form 484 2 Valid Values 37 Oxygen delivery equipment is stationary 38 Certification signed by the physician is on file at the supplier s office AL Ambulation limitations P1 Patient was discharged from the first ZV Replacement item 10642 COND CODE CRCO07 The qualifier indicating the patient s fifth condition is invalid INVALID for this line Use values 37 AL and P1 for CMN form 484 2 and 38 for all DMERC CMN s including CMN form 484 2 Valid Values 37 Oxygen delivery equipment is stationary 38 Certification signed by the physician is on file at the supplier s office AL Ambulation limitations P1 Patient was discharged from the first ZV Replacement item 10643 SERVICE DTP The segment providing the date of service for this line DATE EXC exceeds maximum use When this information is reported MAX USE only 1 occurrence per line may be used 10644 NOT USED 10645 DTE TIME PER DTP02 The qualifier indicating the format used to report the date s FORMAT of service for this line is invalid QUALIFIER INVALID Valid Values D8 Date expressed in CCYYMMDD format RD8 Range of dates expressed in CCYYMMDD CCYYMMDD format 10646 FROM DATE DTPO3 The date of service entered is invalid for this line When INVALID entered this information must be entered ina CCYYMMDD format 10647 FROM DATE DTPO3 The date of service entered is invalid for this line Wh
110. 6 15 6 17 6 18 6 21 6 23 8 23 Claim Status Inquiry CSI 1 2 2 1 10 1 CMN Reject Listing 6 1 6 23 6 25 CMN Rejections 6 24 Connection Requirements 5 3 Customer Support Center 5 2 5 8 Dial Up Setup 5 4 DMACS32 1 2 DMERC specific edits 7 1 8 1 9 1 EDI Edge 1 2 Enrollment Form 1 1 3 1 Products and Services 2 1 2 4 Reviews 3 1 Electronic Remittance Notice ERN 1 2 2 3 5 18 Electronic Reports 1 1 5 18 Report Package 1 1 6 1 6 14 6 21 6 23 Error Listing 6 1 6 21 6 22 Exit see Logoff Front End Edits 7 1 7 196 DMERC 9 1 9 8 Medicare 8 1 8 23 Functional Acknowledgement report 997 4 1 4 5 5 17 6 1 6 5 Health Insurance Portability and Accountability Act HIPAA 7 1 8 1 HyperTerminal 5 1 5 3 5 4 Index Continued Implementation Guide 7 3 Edits 7 1 7 4 8 1 9 1 Logoff 5 28 Loops 4 2 Mailbox Access Facility Menu 5 9 5 28 Medicare specific edits 7 1 8 1 9 1 Online Receipt Verification 1 1 6 1 Password 5 7 5 8 pc Anywhere 5 3 5 4 Privacy Act 2 4 ProComm Plus 5 3 5 4 Received Claims Listing 6 1 6 17 6 18 Stratus Network 5 1 5 28 User Guide 5 1 5 28 Submission Summary 6 1 6 19 6 20 Submitter ID 5 2 Submitter Reports Cover Page 6 1 6 15 6 16 Testing 4 1 4 5 Viewing a File 5 24
111. 60 ENTITY ID NM101 The qualifier identifying the other payer purchased service CODE INVALID provider for this claim is invalid This information is used when a payer is submitting this claim to another payer and should not be submitted by the supplier Valid Value QB Purchased service provider This information is not used for DMERC 10561 ENTITY TYPE NM102 The qualifier identifying the other payer purchased service QUALIFIER provider type is invalid for this claim INVALID This information is used when a payer is submitting this claim to another payer and should not be submitted by the supplier Valid Values 1 Person 2 Non person entity This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 106 Chapter Seven Edit Number Edit Description Element Segment ID Edit Explanation 10562 PUR SER PROV LAST NAME MISSING NM103 The last name or company name is missing for this claim If you have specified the other payer purchased service provider type to be a person this element must contain the last name of that person If the other payer purchased service provider was identified as a non person entity this element must contain the company name This information is used when a payer is submitting this claim to another payer and should not be submitted by the supplier This information is not used for DMERC 10563 OTH PAY PUR SER PROV ID
112. 82 Rendering provider This information is not used for DMERC 10783 ENTITY TYPE NM102 The qualifier identifying the rendering provider type is invalid QUALIFIER for this line INVALID Valid Values 1 Person 2 Non person entity This information is not used for DMERC 10784 REND PROV NM103 The last name or company name is missing for this line If LAST NAME you have specified the rendering provider type to be a MISSING person this element must contain the last name of that person If the rendering provider was identified as a non person entity this element must contain the company name This information is not used for DMERC 10785 REND PROV NM104 The first name of the rendering provider is missing for this FIRST NAME line If you have specified the rendering provider type to be a MISSING person this element must contain the first name of that person This information is not used for DMERC 10786 ID CODE NM108 The qualifier identifying the rendering provider identification QUALIFIER number for this line is invalid INVALID Valid Values 24 Employer s Identification Number 34 Social Security Number XX National Provider Identifier This information is not used for DMERC 10787 REND PROV PRV The segment providing rendering provider information for SPEC INFO this line is missing This information is required when a MISSING rendering provider is identified at the line level This information is not used for DMERC
113. ALID code was entered as it appears on the explanation of benefits from the primary payer This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 20090 ADJUSTMENT CAS14 The claim adjustment reason code indicated on this REASON CODE5 claim is invalid Verify the claim adjustment reason INVALID code was entered as it appears on the explanation of benefits from the primary payer This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 20091 ADJUSTMENT CAS17 The claim adjustment reason code indicated on this REASON CODE6 claim is invalid Verify the claim adjustment reason INVALID code was entered as it appears on the explanation of benefits from the primary payer This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 20092 SUBSCRIBER DATE DMG02 The other insured s date of birth indicated on this claim OF BIRTH INVALID is invalid Verify the century was entered as either 18 19 or 20 This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare This information is used
114. AV Available Not Used The patient refused referral NU Not used This indicator must be used when the submitter answers N in CRC02 S2 Under Treatment ST New Services Requested This information is not used for DMERC 11190 SV4 SEGMENT SV4 The segment providing drug service information for this line NOT ALLOWED is invalid IN X12 VERSION This edit indicates an invalid format and should be resolved by contacting your software vendor This information is not used for DMERC 11191 PROD SER ID SV501 1 The qualifier indicating the type of product service code QUALIFIER used for this line is invalid INVALID Valid Value HC Health care Financing Administration Common Procedural Coding System HCPCS Codes This information is not used for DMERC 11192 SV5 PROC V501 2 The HCPCS code listed in the durable medical equipment CODE NOT EQ service segment does not match the HCPCS code listed in TO SV101 the professional service segment on this claim line PROC CODE This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 202 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 11193 BASIS FOR SV502 The qualifier identifying the type of service units being MEASUREMEN reported is invalid for the durable medical equipment service T CODE segment INVALID Valid Value DA Days This information is not used for DMERC 11195 DME
115. BER NM102 The qualifier identifying the subscriber type is invalid for this ENTITY TYPE claim QUAL INVALID Valid Values 1 Person 2 Non person entity 10110 SUBSCRIBER NM103 The last name or company name is missing for this LAST NAME transaction If you have specified the subscriber type to be a MISSING person this element must contain the last name of that person If the subscriber was identified as a non person entity this element must contain the company name 10111 SUBSCRIBER NM104 The first name of the subscriber is missing for this claim If FIRST NAME you have specified the subscriber type to be a person this MISSING element must contain the first name of that person If the subscriber was identified as a non person entity this element is not used www cignamedicare com edi Revised April 2003 Page 24 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10112 SUBSCRIBER NM108 The qualifier identifying the subscriber identification number ID NUMBER for this claim is invalid QUAL INVALID Valid Values MI Member Identification Number ZZ Mutually Defined 10113 SUBSCRIBER NM109 The subscriber primary identification number is missing for HICN MISSING this subscriber The subscriber s HICN is required for all DMERC claims 10114 SUBSCRIBER N2 The segment providing additional subscriber name ADD NAME information for this claim exceeds
116. C 10335 NOT USED 10336 REPRICER REF02 The adjusted repriced claim number is missing for this claim ADJ CLM NBR MISSING This information is not used for DMERC 10337 INV DVC NBR REF The segment containing the investigational device SEG EXC MAX exemption number information exceeds maximum use USE When this information is reported only 1 occurrence per claim may be used This information is not used for DMERC 10338 NOT USED 10339 INV DVC NBR REF02 The investigational device exemption number is missing for MISSING this claim This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 55 Edit Edit Description Element Edit Explanation Number Segment ID 10340 CH CLM NBR REF The segment containing the claim number for SEG EXC MAX clearinghouses and other transmission intermediaries USE information exceeds maximum use When this information is reported only 1 occurrence per claim may be used This information is not used for DMERC 10341 NOT USED 10342 CH CLM NBR REF02 The claim number for clearinghouses and other MISSING transmission intermediaries is missing for this claim This information is not used for DMERC 10343 APG NBR SEG REF The segment containing the ambulatory patient group EXC MAX USE number information exceeds maximum use When this information is reported only 4 occurrences per claim may be used This information i
117. C EDI Manual Revised June 2002 Chapter Six Electronic Reports One of the many advantages of transmitting your claims electronically is the ability to track your claims as soon as they are received by our system MCM 3021 2 This allows for more control over the claim s processing cycle The following reports are generated to assist you in the tracking of your claims e Online Receipt Verification e 997 Functional Acknowledgment report 997 e Electronic Report Package Report 716001 Submitter Reports Cover Page Report 716002 Received Claims Listing Report 716004 Submission Summary Report 716003 Error Listing Report 716006 CMN Reject Listing All electronic reports provided by CIGNA Medicare will be available to download for up to seven days However if a download is attempted and failed on a report that report will no longer be available after three days If necessary the report can be redistributed to your Stratus mailbox for a period of 30 days from the date the file was sent You may contact the EDI Department for assistance The next few pages contain information regarding these reports along with examples For information on downloading reports in the Stratus Network please see Chapter 5 Online Receipt Verification Once a file is transmitted via the Stratus Network the supplier will automatically receive verification electronically that the transmission was successful Although this con
118. CEEDS MAX cannot be greater than 5 positions This information is not used for DMERC 11105 CONTRACT CN103 The value entered as the line item charge is invalid This EXCEEDS MAX amount cannot have greater than two positions to the right DECIMALS of the decimal This information is not used for DMERC 11106 CLAIM LEVEL REFO1 A claim level error occurred due to invalid use of a qualifier REF QUAL identifying the use of a REF segment for this claim If you INVALID receive this error please contact your software vendor or refer to the 837 Implementation Guide for valid segments to use for this claim 11107 LINE LEVEL REFO1 A line level error occurred due to invalid use of a qualifier REF QUAL identifying a REF segment for this line item If you receive INVALID this error please contact your software vendor or refer to the 837 Implementation Guide for valid REF segments to use for this line 11108 CLAIM LEVEL AMTO1 A claim level error occurred due to invalid use of a qualifier AMT QUAL identifying an AMT segment for this claim If you receive this INVALID error please contact your software vendor or refer to the 837 Implementation Guide for valid AMT segments to use for this claim 11109 LINE LEVEL AMTO1 A line level error occurred due to invalid use of a qualifier AMT QUAL identifying an AMT segment for this line If you receive this INVALID error please contact your software vendor or refer to the 387 Implementation Guide for
119. CIGNA Medicare is unable to release any information to a supplier The beneficiary needs to contact the Customer Service Department toll free at 800 899 7095 The six valid error codes for CMN rejections are as follows Error EDIT Edit Explanation Code DESCRIPTION 3030 INIT DATE The initial CMN transmitted electronically has the same initial date as the DUP original CMN on file for this procedure code This error occurs when a duplicate initial CMN was transmitted An initial CMN should be transmitted only with the initial claim for that item For example a claim is transmitted for a wheelchair with a date of service of 01 14 01 along with an initial CMN with an initial date of 01 14 01 The following month a claim is transmitted with the date of service 02 14 01 along with the same CMN previously transmitted with an initial date of 01 14 01 Since CIGNA Medicare already has the first initial CMN with an initial date of 01 14 01 the duplicate CMN would be rejected with an error code of 3030 Resolution Suppliers should check their software to make sure that a CMN will be transmitted only when necessary Remember to only transmit a CMN when necessary and not with every subsequent claim www cignamedicare com edi Page 26 Chapter Six Error EDIT Edit Explanation Code DESCRIPTION 3031 INIT DATE lt PREV END DATE CUR REC REV DATE lt PREV The initial CMN transmitted electronically has an initial date that is prior to the
120. D DMERC EDI Manual Revised April 2003 Front End Edits Page 53 Edit Edit Description Element Edit Explanation Number Segment ID 10318 MED XOVER REF02 The mandatory Medicare crossover indicator is invalid for CODE INVALID this claim Valid Values Y 4081 N Regular Crossover This information is used when a payer is submitting this claim to another payer and should not be submitted by the supplier This information is not used for DMERC 10319 MAM CERT REF The segment containing the mammography certification SEG EXC MAX information exceeds maximum use When this information is USE reported only 1 occurrence per claim may be used This information is not used for DMERC 10320 NOT USED 10321 MAM CERT REF02 The mammography certification number is missing for this NBR MISSING claim This information is not used for DMERC 10322 PRIOR AUTH REF The segment containing the prior authorization or referral NBR SEG EXC number information exceeds maximum use When this MAX USE information is reported only 2 occurrences per claim may be used This information is not used for DMERC 10323 NOT USED 10324 PRIOR AUTH REF02 The prior authorization or referral number is missing NBR MISSING This information is not used for DMERC 10325 ORIG REF NBR REF The segment containing the original reference number SEG EXC MAX information exceeds maximum use When this information is USE reported only 1 occurrence per clai
121. D8 Date expressed in format CCYYMMDD This information is not used for DMERC 10714 INT TREAT DTP03 The initial treatment date entered is invalid for this line DATE INVALID When entered this information must be entered in a CCYYMMDD format This information is not used for DMERC 10715 INT TREAT DTP03 The initial treatment date entered is invalid for this line DATE FUTURE When entered this information must not be greater than DATE today s date This information is not used for DMERC 10716 SIMI ILL SYM DTP The segment providing the onset of similar illness or ONSET DT symptom date for this line exceeds maximum use When EXC MAX USE this information is reported only 1 occurrence per line may be used This information is not used for DMERC 10717 NOT USED www cignamedicare com edi Revised April 2003 Page 134 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10718 DTE TIME PER DTP02 The qualifier indicating the format used to report the onset of FORMAT similar symptoms or Illness date for this line is invalid QUALIFIER INVALID Valid Value D8 Date expressed in format CCYYMMDD This information is not used for DMERC 10719 SIMI ILL SYM DTP03 The date of similar symptoms or illness entered is invalid for ONSET DATE this line When entered this information must be entered in INVALID a CCYYMMDD format This information is not used for DMERC 10720 SIMI
122. DMERC billers CIGNA Medicare provides this software for a fee of 25 00 to cover shipping and handling costs AT amp T charges all users a monthly fee of 3 00 for an AT amp T account and UserID If you are using the AT amp T Global Network you will be billed by AT amp T for their network usage at the following rates e Hourly rate for prime time usage 6 50 8 00 a m to 8 00 p m ET e Hourly rate for non prime time usage 4 45 8 00 p m to 8 00 a m ET e Hourly surcharge for an 800 number if a local node is unavailable 6 00 Note You will not incur expenses from the phone company if dialing the local AT amp T number provided AT amp T rates are subject to change Minimum hardware requirements Requirements listed below are minimumrequirements for running the AT amp T Passport for Windows communications software Some PCs may require higher standards e Any PC capable of running MS Windows version 95 or higher in 386 enhanced mode or better e At least 2 5 MB of available disk space e At least 12 MB of RAM but more is recommended We highly recommend at least 32 MB of RAM e A 3 5 inch 1 44 MB disk drive required for installation e A mouse optional but highly recommended e A serial port e A Hayes compatible asynchronous modem that is 2400 bps or faster at least 9600 bps is highly recommended Note Rockwell modems are NOT considered Hayes compatible and therefore cannot be supported e An analog telephone line
123. DS exceed 15 positions MAXIMUM This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 182 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 11044 ADJ UNITS CAS10 The value entered as the line adjustment adjusted units EXCEEDS MAX claim level amount is invalid If reported do not exceed the DECIMAL maximum number of positions to the right of the decimal PLACES point This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare This information is not used for DMERC 11045 ADJ AMOUNT CAS12 The value entered as the line adjustment amount is invalid EXCEEDS If reported the amount cannot exceed 18 positions MAXIMUM This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare This information is not used for DMERC 11046 ADJ AMOUNT CAS12 The value entered as the line adjustment amount is invalid CANNOT HAVE If reported this amount cannot exceed two positions to the gt 2 DEC right of the decimal point PLACES This information is used for
124. DT EXC MAX exceeds maximum use When this information is reported USE only 1 occurrence per line may be used This information is not used for DMERC 10707 NOT USED 10708 DTE TIME PER DTP02 The qualifier indicating the format used to report the acute FORMAT manifestation date for this line is invalid QUALIFIER INVALID Valid Value D8 Date expressed in format CCYYMMDD This information is not used for DMERC www cignamedicare com edi Revised April 2003 Front End Edits Page 133 Edit Edit Description Element Edit Explanation Number Segment ID 10709 ACUTE MANIF DTPO3 The acute manifestation date entered is invalid for this line DATE INVALID When entered this information must be entered in a CCYYMMDD format This information is not used for DMERC 10710 ACUTE MANIF DTPO3 The acute manifestation date entered is invalid for this line DATE FUTURE When entered this information must not be greater than DATE today s date This information is not used for DMERC 10711 INITIAL TREAT DTP The segment providing the initial treatment date for this line DT EXC MAX exceeds maximum use When this information is reported USE only 1 occurrence per line may be used This information is not used for DMERC 10712 NOT USED 10713 DTE TIME PER DTP02 The qualifier indicating the format used to report the initial FORMAT treatment date for this line is invalid QUALIFIER INVALID Valid Value
125. FUTURE DATE this line When entered this information must not be greater than today s date This information is not used for DMERC 10686 O2 SAT ABG DTP The segment providing the oxygen saturation arterial blood DT EXC MAX gas test date for this line exceeds maximum use When this USE information is reported only 3 occurrences per line may be used 10687 NOT USED 10688 DTE TIME PER DTP02 The qualifier indicating the format used to report the oxygen FORMAT saturation arterial blood gas test for this line is invalid QUALIFIER INVALID Valid Value D8 Date expressed in format CCYYMMDD 10689 O2 SAT ABG DTPO3 The oxygen saturation arterial blood gas test date entered is DATE INVALID invalid for this line When entered this information must be entered in a CCYYMMDD format www cignamedicare com edi Revised April 2003 Page 130 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10690 O2 SAT ABG DTPO3 The oxygen saturation arterial blood gas test date entered is DATE FUTURE invalid for this line When entered this information must not DATE be greater than today s date 10691 SHIPPED DT DTP The segment providing the shipped date for this line EXC MAX USE exceeds maximum use When this information is reported only 1 occurrence per line may be used This information is not used for DMERC 10692 NOT USED 10693 DTE TIME PER DTP02 The qualifier indicating the f
126. G Thursday H Friday J Saturday K Sunday L Monday through Thursday N As directed O Daily Mon through Fri SA Sunday Monday Thursday Friday Saturday SB Tuesday through Saturday SC Sunday Wednesday Thursday Friday Saturday SD Monday Wednesday Thursday Friday Saturday SG Tuesday through Friday SL Monday Tuesday and Thursday SP Monday Tuesday and Friday SX Wednesday and Thursday SY Monday Wednesday and Thursday SZ Tuesday Thursday and Friday W Whenever necessary This information is not used for DMERC 10773 TIME CODE INVALID HSD08 The qualifier indicating the time of visits being reported for home health deliveries is not valid for this line Valid Values D A M E P M F As directed This information is not used for DMERC 10774 PRICE REPRIC E METH HCPO1 Region D DMERC EDI Manual Revised April 2003 The pricing methodology code used to indicate how this line Front End Edits Page 141 Edit Number Edit Description Element Segment ID Edit Explanation INVALID has been priced or repriced is invalid Valid Values 00 Zero pricing not covered under contract 01 Priced as billed at 100 02 Priced at the standard fee schedule 03 Priced at a contractual percentage 04 Bundled pricing 05 Peer review pricing 06 Per diem pricing 07 Flat rate pricing 08 Combination pricing 09 Mate
127. HMM format must be used where CC Century YY Year MM Month DD Day HH Hour based on 24 hour clock MM Minute e All dates must be less than the current date When reporting a span of dates the from date must be prior to the to date Names Generally names are reported as last name or company name middle name and first name e Last Name or Company Name This name field requires data to be present in each occurrence of a name The first position of this name element cannot contain spaces e Middle Name This name field is optional and should not be used unless a person is being reported and the middle name is known e First Name If a person is being reported the first name must be present When submitted the first position cannot contain spaces and the first three characters cannot be any of the following MR DR JR MR DR JR Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 3 Addresses When reporting the address you must include a street address a city a state and a zip code If the address being reported is outside of the country then a valid country code must also be submitted e Street Address When submitted the first position of this element cannot contain a space When an address requires a second line the first position must contain data Characters such as amp etc are allowed however we discourage use of these symbols e City When submitting address i
128. IER number for this transaction is invalid INVALID Valid Values 24 Employer s Identification Number 34 Social Security Number XX Health Care Financing Administration National Provider Identifier This information is not used for DMERC 10430 PROV CODE PRVO1 The qualifier identifying the type of provider being reported INVALID for this claim is invalid Valid Value PE Performing This information is not used for DMERC 10431 REF ID PRV02 The qualifier identifying the type of identification number QUALIFIER being reported for the rendering provider is invalid for this INVALID claim Valid Value ZZ Mutually Defined This information is not used for DMERC 10432 ADD REND N2 The segment providing additional rendering provider name PROV NAME information for this claim exceeds maximum use When this EXC MAX USE information is reported only 1 occurrence per transaction may be used This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 76 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10433 REND PROV REF The segment containing additional rendering provider SEC ID EXC identification information exceeds maximum use When this MAX USE information is reported only 5 occurrences per claim may be used This information is not used for DMERC 10434 REF ID REFO1 The qualifier for the rendering provider secondary QUALIFIER ident
129. June 2002 Page 6 Chapter Five 5 After your modem has connected you will see a blank screen with a blinking cursor 6 Press Enter The following screen verifies that you have successfully dialed into the Stratus Network If this screen does not appear make sure that your Scroll Lock is not on If the Scroll Lock is on press the Scroll Lock button on your keyboard to turn it off and press Enter If you have timed out you will need to redial You have dialed into CIGNA s gateway service Center Please type login followed by your user id and then press the return key 7 Type login in lowercase letters followed by a space and your User ID MBXXXX The alpha characters in your User ID need to be in uppercase i e login MBO001A Press Enter Region D DMERC EDI Manual Revised June 2002 Stratus Network User Guide Page 7 8 You will then be prompted to enter your password You have dialed into CIGNA s gateway service Center Please type login followed by your user id and then press the return key login MBOO1A Password _ 9 Type your password and press Enter If this is the first time you have logged in a The initial password will be FIRST FIRST must be entered in all uppercase letters b You will be prompted to change the password the first time you log in c Once the new password is entered you will be prompted to enter the password a second time for verification Please remember
130. L for home health deliveries is not valid for this claim INVALID Valid Values 7 Day 35 Week This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 71 Edit Number Edit Description Element Segment ID Edit Explanation 10408 PATTERN CODE QUAL INVALID HSD07 The qualifier indicating the pattern code for visits being reported for home health deliveries is not valid for this claim Valid Values SB Tuesday through Saturday SC Sunday Wednesday Thursday Friday Saturday SD Monday Wednesday Thursday Friday Saturday SG Tuesday through Friday SL Monday Tuesday and Thursday SP Monday Tuesday and Friday SX Wednesday and Thursday SY Monday Wednesday and Thursday SZ Tuesday Thursday and Friday W Whenever necessary This information is not used for DMERC 10409 TIME CODE QUAL INVALID HSD08 The qualifier indicating the time of visits being reported for home health deliveries is not valid for this claim Valid Values D A M E P M F As directed This information is not used for DMERC 10410 REF PROV NAME EXC MAX USE NM1 The segment providing the referring provider name information for this claim exceeds maximum use When this information is reported only 2 occurrences per claim may be used This information is not used for DMERC 10411 REF PR
131. LID this information must be entered in a valid CCYYMMDD format This information is not used for DMERC 10163 PAT DATE OF PATO6 The patient s date of death when the patient is not the DEATH subscriber entered is invalid for this claim When entered FUTURE DATE this information must not be greater than today s date This information is not used for DMERC 10164 PAT WEIGHT PATO7 The code used to indicate the measurement of the patient s MEA QUAL weight when other than the subscriber is invalid for this INVALID claim Valid Value GR Grams This information is not used for DMERC 10165 PAT WEIGHT PATO08 The patient s when other than the subscriber weight is MISSING missing for this claim This information is not used for DMERC 10166 PAT PREG IND PATO9 The pregnancy indicator when the patient is other than the CODE INVALID subscriber is invalid for this claim Valid Value Y Indicating patient is pregnant This information is not used for DMERC 10167 PAT NAME NM1 The segment providing name information for the patient SEGMENT EXC when other than insured exceeds maximum use MAX USE This information is not used for DMERC 10168 PAT NAME NM101 The qualifier identifying the patient when other than the QUAL INVALID subscriber for this claim is invalid Valid Value QC Patient This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 32 Chapter Seven
132. Length of need for CMN Form 484 2 is missing for this line This information is required on all DMERC claims requiring a CMN Form 484 2 10618 ARTERIAL BLOOD GAD LEV MISSING CR510 The arterial blood gas ABG test results are missing for this line This information must be used to report the ABG for question number 1A on CMN Form 484 2 10619 O2 SAT LEVEL MISSING CR511 Oxygen saturation test results are missing for this line This information must be used to report the oxygen saturation test for question number 1B on CMN Form 484 2 www cignamedicare com edi Revised April 2003 Page 120 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10620 O2 TEST CR512 The condition under which the patient was tested in COND CODE response to question 3 on CMN Form 484 2 is invalid for INVALID this line Valid Values E Exercising R At rest on room air S Sleeping 10621 O2 TEST CR513 The qualifier indicating the findings of oxygen tests FINDINGS performed on patient in response to question 8 on CMN INVALID form 484 2 is invalid for this line Valid Value 1 Dependant edema suggesting congestive heart failure 10622 O2 TEST CR514 The qualifier indicating the finding of oxygen tests performed FINDINGS on patient in response to question 9 on CMN Form 484 2 is INVALID invalid for this line Valid Value 2 P Pulmonale on electrocardiogra
133. N Region D DMERC EDI Manual Revised June 2002 Stratus Network User Guide Page 23 The filename suffixes explain the status of each file as follows You will see this mask after the file has been successfully uploaded or downloaded We recommend you search for the file on your computer before downloading files again See Locating Downloaded Files on page 19 When a file is aborted during an upload this extension will appear on the filename Any file with a pt extension will need to be uploaded again This extension is not very common This means that the Stratus Network has retained the file in a raw format for future reference Files restored by the Stratus Network will have this extension Files restored by CIGNA Medicare will not contain this extension When a file is aborted during a download the fl extension will be added to the file Any file with a fl extension must be downloaded again Files received that do not contain a valid format may receive a bad extension If this occurs double check the file being sent is in the ANSI X12 format 3 Press Enter to display all files Filename SUFFIXES File was ALREADY processed bk Back version of a file File contains partial info JEL File transmission failed save File under retention management bad File contains bad data Please enter the MASK for the files you wish to list press lt RETURN gt to list all files or for masking examples ENTER Y
134. N This edit indicates an invalid format and should be resolved by contacting your software vendor This information is not used for DMERC 11142 X RAY AVAIL N2 The segment providing additional name information for the IND MUST Y referring provider for this claim is invalid N OR This edit indicates an invalid format and should be resolved by contacting your software vendor This information is not used for DMERC 11143 N2 SEGMENT N2 The segment providing additional name information for the NOT ALLOWED rendering provider for this claim is invalid IN X12 VERSION This edit indicates an invalid format and should be resolved by contacting your software vendor This information is not used for DMERC 11144 N2 SEGMENT N2 The segment providing additional name information for the NOT ALLOWED service facility location for this claim is invalid IN X12 VERSION This edit indicates an invalid format and should be resolved by contacting your software vendor This information is not used for DMERC 11145 N2 SEGMENT N2 The segment providing additional name information for the NOT ALLOWED supervising provider for this claim is invalid IN X12 VERSION This edit indicates an invalid format and should be resolved by contacting your software vendor This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 195 Edit Edit Description Element Edit Explanatio
135. NT EXC maximum use When this information is reported only 1 MAX USE occurrence per claim may be used This information is not used for DMERC 10207 NOT USED 10208 ORDER DATE DTP02 The qualifier indicating the format used to report the order FMT QUAL date for this claim is invalid INVALID Valid Value D8 Date expressed in format CCYYMMDD This information is not used for DMERC 10209 ORDER DATE DTPO3 The order date entered is invalid for this claim When INVALID FMT entered this information must be entered in a valid CCYYMMDD format This information is not used for DMERC 10210 ORDER DATE DTPO3 The order date entered is invalid for this claim When FUTURE DATE entered this information must not be greater than today s date This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 40 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10211 INIT DTP The segment providing the initial treatment date for this TREATMENT claim exceeds maximum use If this information is reported DT SEG EXC only 1 occurrence per claim may be used MAX USE This information is not used for DMERC 10212 NOT USED 10213 INIT DTP02 The qualifier indicating the format used to report the initial TREATMENT treatment date for this claim is invalid DT FMT Q INVALID Valid Value D8 Date expressed in format CCYYMMDD This information is not use
136. ON CODE1 claim is invalid Verify the claim adjustment reason INVALID code was entered as it appears on the explanation of benefits from the primary payer This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 20087 ADJUSTMENT CAS05 The claim adjustment reason code indicated on this REASON CODE2 claim is invalid Verify the claim adjustment reason INVALID code was entered as it appears on the explanation of benefits from the primary payer This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 20088 ADJUSTMENT CASO09 The claim adjustment reason code indicated on this REASON CODE3 INVALID claim is invalid Verify the claim adjustment reason code was entered as it appears on the explanation of benefits from the primary payer This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare Region D DMERC EDI Manual Revised April 2003 Front End Edits Medicare Page 13 Edit Number EDIT DESCRIPTION ElementID Edit Explanation 20089 ADJUSTMENT CAS11 The claim adjustment reason code indicated on this REASON CODE4 claim is invalid Verify the claim adjustment reason INV
137. OUR SELECTION Your mailbox contains the following files 1 MOOLAT_2001 04 03 000001 7 cp f 4096 04 03 2001 16 34 11 strm Press lt RETURN gt to continue _ 4 After viewing the list of files press Enter to return to the Mailbox Access Facility menu www cignamedicare con edi Revised June 2002 Page 24 Chapter Five Viewing a File The Mailbox Access Facility menu allows you to view files available to download and files you have recently uploaded This is helpful if you are looking for a particular file and you have several available 1 From the Mailbox Access Facility menu type 4 and press Enter ttteteeteeeteette Mailbox Access Facility t t t ttettettee User Id MBOO1A 0 Set User Defaults Current Settings 1 Change Data Type 2 Number of Files DATA TYPE SEND_ANSITEST 3 List file names MAILBOX SD_CATI INBOUND 4 View a file Perera to ss sono sno St esas ae PROTOCOL PROMPT 6 Upload Put a file in Mailbox FILE TYPE STREAM 7 Display Activity Log PRINTER_PAUSE NO INITIAL MENU OPT NONE 99 Return to main menu Network 7 ENTER YOUR SELECTION 4_ 2 The following screen will appear Press Enter to see a list of all files Please enter the MASK for the files you wish to download press lt RETURN gt to list all files or for masking examples ENTER YOUR SELECTION Region D DMERC EDI Manual Revised June 2002 3
138. OV NAME QUAL INVALID NM1 The segment providing the referring provider name information for this claim is invalid If used the first occurrence of the referring provider name segment at the claim level must contain information on the referring provider This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 72 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10412 REF PROV NM1 The segment providing the referring provider name NAME QUAL information for this claim is invalid If used the second INVALID occurrence of the referring provider name segment at the claim level must contain information on the primary care provider This information is not used for DMERC 10413 NOT USED 10414 ENTITY TYPE NM102 The qualifier indicating the referring provider type is invalid QUALIFIER for this claim INVALID Valid Values 1 Person 2 Non person entity This information is not used for DMERC 10415 REF PROV NM103 The last name or company name is missing for this claim If LAST NAME you have specified the referring provider type to be a MISSING person this element must contain the last name of that person If the referring provider was identified as a non person entity this element must contain the company name This information is not used for DMERC 10416 REF PROV NM104 The first name of the referring provider is missing for this FIR
139. PE QUAL information being sent with this claim is invalid INVALID Valid Values ADD Additional information CER Certification narrative DCP Goals rehabilitation potential or discharge plans DGN Diagnosis description PMT Payment TPO Third party organization notes 10354 AMBO PAT CR101 The code used to indicate the measurement of the patient s WEIGHT MEA weight is invalid for this claim This is only used when Q INVALID reporting information to justify extra ambulance services Valid Value LB Pound This information is not used for DMERC 10355 AMBO CR103 The code used to indicate the type of ambulance TRANSPORT transportation for this claim is invalid CODE INVALID Valid Values Initial trip R Return trip T Transfer trip X Round trip This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 57 Edit Edit Description Element Edit Explanation Number Segment ID 10356 AMBO CR104 The code used to indicate the reason for the ambulance REASON transport for this claim is invalid CODE INVALID Valid Values A Patient was transported to nearest facility for care of symptoms complaints or both Can be used to indicate that the patient was transferred to a residential facility B Patient was transported for the benefit of a preferred physician C Patient was transported for the nearness of family members D Patient wa
140. R identification number information for this claim is invalid INVALID This information is used when a payer is submitting this claim to another payer and should not be submitted by the supplier Valid Values 1W Member identification number 23 Client number IG Insurance policy number SY Social Security Number this may not be used for Medicare 10543 OTH PAY PAT REFO2 The other payer s patient secondary identification number is SEC ID missing for this claim MISSING This information is used when a payer is submitting this claim to another payer and should not be submitted by the supplier www cignamedicare com edi Revised April 2003 Page 102 Chapter Seven Edit Number Edit Description Element Segment ID Edit Explanation 10544 OTH PAY REF PRO EXC MAX USE NM1 The segment providing the other payer s referring provider name information for this claim exceeds maximum use When this information is reported only 1 occurrence per claim may be used This information is used when a payer is submitting this claim to another payer and should not be submitted by the supplier 10545 ENTITY ID CODE INVALID NM1 The segment providing the referring provider name information for this claim is invalid If used the first occurrence of the other payer referring provider name segment at the claim level must contain information on the referring provider This information is used w
141. RENTAL SV504 The DME rental price is missing from this Durable Medical AND PURCH Equipment segment As a DME purchase price was not AMT MISSING provided this is a required element when this segment is used This information is not used for DMERC 11196 DME RENT SV504 You have included a rental unit price indicator to indicate the BILL FREQ frequency at which the rental equipment is billed however a MISSING DME rental price was not included in the Durable Medical RENTAL AMT Equipment segment This information is not used for DMERC 11197 DMERENTAL SV504 The DME Rental Price being reported is invalid When used AMOUNT this information must contain numeric values only INVALID This information is not used for DMERC 11198 DME RENTAL SV504 The value representing the DME Rental price reported PRICE amount exceeds 18 positions EXCEEDS MAXIMUM This information is not used for DMERC 11199 DME RENT SV504 The value representing the DME rental price reported PRC CANNOT exceeds two positions to the right of the decimal point HAVE gt 2 DEC PLACES This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Page 203 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 11200 DME SV505 The DME purchase price being reported is invalid When PURCHASE used this information must contain numeric values only AMOUNT INVALID This information is not used for DMERC
142. RT line MISSING This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 137 Edit Edit Description Element Edit Explanation Number Segment ID 10742 CLIN LAB IMP REF The segment containing additional Clinical Laboratory AM EXC MAX Improvement Amendment CLIA Number information USE exceeds maximum use When this information is reported only 1 occurrence per line may be used This information is not used for DMERC 10743 NOT USED 10744 CLIN LAB IMP REF02 The Clinical Laboratory Improvement Amendment CLIA AM MISSING number is missing for this line This information is not used for DMERC 10745 REF CLIA FAC REF The segment containing additional referring CLIA facility ID EXC MAX identification information exceeds maximum use When this USE information is reported only 1 occurrence per line may be used This information is not used for DMERC 10746 NOT USED 10747 REF CLIA REF02 The referring CLIA facility identification number is missing MISSING for this line This information is not used for DMERC 10748 IMM BTCH REF The segment containing the immunization batch number EXC MAX USE information exceeds maximum use When this information is reported only 1 occurrence per line may be used This information is not used for DMERC 10749 NOT USED 10750 IMM BTCH REF02 The immunization batch number is missing for this li
143. Region D DMERC EDI Department Revised April 2003 Region D DMERC EDI Manual EDI Working together to meet your needs CIGNA HealthCare CENTERS for MEDICARE amp MEDICAID SERVICES Medicare Administration Table of Contents Introduction Chapter One Benefits of Billing Electronically 1 Chapter Two EDI Products and ServicesS eeeeeeeeeererreererrrrsrerrsrerrrern reee 1 Chapter Three EDI Reviews 0 cccccccceeceeeeeeeeeneeeeeeeeeeecaeeeeteteeeeeteneesneeeeess 1 Chapter Four Testinhgerenn eenaa EEEE a A EEEE toe 1 Chapter Five Stratus Network Users Guide ren 1 Connection REQUIFEMENIS Ss isacacau ceedecsteudasy tevatasan cds cues scene tebaxa devadseesiageh cas canpadaedtbed 3 Dial Up SetU Ptr errr ners Comer centre mrcpen irony arr nrate E E 4 Connect and LOJON eese sie vesgienep a E teaser EgeRate 5 Mailbox Access Facility Menu sesseeeeeeseeseirrssssserrrresstsrrrrrsserrrrrrrrsssrrtrrrrreeren 9 Change data Ty Deepal eeeisratastessesecan tas cahacdaedeeseastink deeateaaiiseas ha deamicanecaneres 12 Upload Put a RleinMailDOXx 5 cidserventenes eines dat telats rieieaananenn Geena 14 Download Get a file from MailbOxeicennauscwe es ieee 17 Locating dOwnlOad edie x3 ciscuctiegteuiete dest vest Muitideeda sui bhace dod chews 19 Opening Your Downloaded FileS uv ss siec lt acces covets savevegneveutines coer ven iaeeteaneitiemeeetk 21 tist Pile Names esetre gees Vea diy vont E EE E E cena 2
144. SEC EXC MAX USE NM1 The segment providing the other payer service facility name information for this claim exceeds maximum use When this information is reported only 1 occurrence per claim may be used This information is not used for DMERC 10567 ENTITY ID CODE INVALID NM101 The qualifier identifying the other payer service facility location for this claim is invalid This information is used when a payer is submitting this claim to another payer and should not be submitted by the supplier Valid Values 77 Service location FA Facility LI Independent lab TL Testing laboratory This information is not used for DMERC 10568 ENTITY TYPE QUALIFIER INVALID NM102 The qualifier identifying the other payer service facility type is invalid for this claim This information is used when a payer is submitting this claim to another payer and should not be submitted by the supplier Valid Value 2 Non person entity This information is not used for DMERC 10569 SER FAC NAME MISSING NM103 The last name or company name is missing for this claim If you have specified the other payer service facility type to be a person this element must contain the last name of that person If the other payer service facility was identified as a non person entity this element must contain the company name This information is used when a payer is submitting this claim to another pay
145. SSING NTE The segment containing narrative information for this line is missing The procedure code submitted requires narrative information be sent 40053 SERVICE NM1 The segment containing the service facility location FACILITY information is missing If an oxygen certification form is being LOCATION sent with this line this is a required segment MISSING 40054 ORDERING NM103 The ordering provider s last name was entered in an invalid PROVIDER LAST format Verify the first two positions of the ordering provider s NAME INVALID last name are alpha characters and do not contain spaces Make sure the first three positions of the ordering provider s last name are not any of the following MR MR DR DR JR or JR 40055 ORDERING NM104 The ordering provider s first name was entered in an invalid PROVIDER FIRST format Verify the first position of the ordering provider s first NAME INVALID name is an alpha character and does not contain spaces Make sure the first three positions of the ordering provider s last name are not any of the following MR MR DR DR JR or JR 40056 ORDERING NM105 The ordering provider s middle name was entered in an PROVIDER invalid format Verify only alpha characters are present MIDDLE NAME INVALID 40057 ORDERING N301 The ordering provider s address listed on this claim was PROVIDER entered in an invalid format Verify the first position of the ADDRESS1 address information does not contain a space
146. ST NAME claim If you have specified the referring provider type to be MISSING a person this element must contain the first name of that person If the referring provider was identified as a non person entity this element is not used This information is not used for DMERC 10417 ID CODE NM108 The qualifier identifying the referring provider identification QUALIFIER number for this claim is invalid INVALID Valid Values 24 Employers Identification Number 34 Social Security Number XX Health Care Financing Administration National Provider Identifier This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 73 Edit Edit Description Element Edit Explanation Number Segment ID 10418 PROVIDER PRV01 The qualifier identifying the type of provider being reported CODE INVALID for this claim is invalid Valid Value RF Referring This information is not used for DMERC 10419 REF ID PRV02 The qualifier identifying the type of identification number QUALIFIER being reported for the referring provider is invalid for this INVALID claim Valid Value ZZ Mutually defined This information is not used for DMERC 10420 ADD REF PRO N2 The segment providing additional Referring Provider name NAME INFO information for this claim exceeds maximum use When this EXC MAX USE information is reported only 1 occurrence per transaction may be used This inf
147. Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 11054 ADJ AMOUNT CAS18 The value entered as the line level adjusted amount is CANNOT HAVE invalid If reported this amount cannot exceed two positions gt 2 DEC to the right of the decimal point PLACES This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare www cignamedicare com edi Revised April 2003 Page 184 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 11055 ADJUSTED CAS19 The value entered as the line level adjusted units of service UNITS is invalid If reported this amount cannot exceed 15 EXCEEDS positions MAXIMUM This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 11056 ADJ UNITS CAS19 The value entered as the line level adjusted units of service EXCEEDS MAX amount is invalid If reported do not exceed the maximum DECIMAL number of positions to the right of the decimal point PLACES This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 11057 PERCENT FRMO5 The val
148. Stratus Network User Guide Page 25 The following screen will list the files available to download and or files that you have just uploaded into your Stratus Network mailbox Please enter the MASK for the files you wish to download press lt RETURN gt to list all files or for masking examples ENTER YOUR SELECTION Your mailbox contains the following files 1 MOO1AT_ 2001 04 03 000001 7 cp 4096 04 03 2001 16 34 Please enter the number corresponding to your file choice or q to quit ENTER YOUR SELECTION _ 11 strm To select the file that you wish to view type the number that corresponds to the file and press Enter The file information will appear When you are finished viewing the current information press Enter to return to the previous screen At that time you may select another file to view Isa oo o0 Z2Z x999 22 05440 YOUR ANSI CLAIM DATA HERE 001 TEA 1 000000001 Ferien END Press lt RETURN gt to continue Enter 1 to view another file 2 to return to the menu 000626 08 Follow the instructions on the screen to continue view another file or return to the Mailbox Access Facility menu www cignamedicare con edi Revised June 2002 Page 26 Chapter Five Activity Log View your activity log to verify that your transmission was received by the Stratus Network This information can be very helpful when trying to determine why you have not receive
149. T Height R1 Hemoglobin R2 Hematocrit R3 Epoetin starting dosage R4 Creatin ZO Oxygen used to report the oxygen saturation test results when tested on 4 LPM for DMERC Form 484 2 11217 PROD SVC ID SVD03 1 The qualifier indicating the line adjudication product or QUALIFIER service code is invalid for this line MISSING INVA LID Valid Values HC Health Care Financing Administration Common Procedural Coding System HCPCS codes ZZ Mutually defined 11218 SV5 SEGMENT SV5 The segment providing durable medical equipment service EXCEEDS information for this line exceeds maximum use When this MAXIMUM USE information is reported only occurrence per claim line may be used This information is not used for DMERC 11219 2410 LIN LIN The segment providing drug identification information for this INVALID FOR line is invalid X12 VERSION This edit indicates an invalid format and should be resolved by contacting your software vendor www cignamedicare com edi Revised April 2003 Page 206 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 11220 LIN DRUG ID LIN The segment providing the drug identification information SEGMENT EXC exceeds maximum use When this information is reported MAX USE when this information is reported no more than 25 occurrences per claim line may be used 11221 PROD SER ID LINO2 The qualifier indicating the type
150. T FMT Q discharge date for this claim is invalid INVALID Valid Value D8 Date expressed in format CCYYMMDD This information is not used for DMERC 10294 DISCHARGE DTP03 The hospitalization discharge date entered is invalid for this DT INVALID claim When entered this information must be entered in a FMT CCYYMMDD format This information is not used for DMERC 10295 DISCHARGE DTP03 The hospitalization discharge date entered is invalid for this DT FUTURE DT claim When entered this information must not be greater than today s date This information is not used for DMERC 10296 RLINQ CARE DTP The segment providing the date of assumed and DT SEG EXC relinquished care for this claim exceeds maximum use If MAX USE this information is reported only 2 occurrences per claim may be used This information is not used for DMERC 10297 NOT USED 10298 RLINQ CARE DTP02 The qualifier indicating the format used to report the DT FMT Q assumed and relinquished care date for this claim is invalid INVALID Valid Value D8 Date expressed in format CCYYMMDD This information is not used for DMERC 10299 RLINQ CARE DTPO3 The date assumed relinquished care entered is invalid for DT INVALID this claim When entered this information must be entered FMT in a CCYYMMDD format This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 50 Chapter Seven Edit Edit Description Number Element Segment ID
151. T NAME this transaction If you have specified the credit debit MISSING cardholder to be a person this element must contain the first name of that person This information is not used for DMERC 11122 CREDIT DEBIT NM108 The qualifier identifying the credit debit cardholder s ID CODE QUAL identification number is invalid for this transaction INVALID Valid Values MI Member Identification Number This information is not used for DMERC 11123 CREDIT DEBIT NM109 The credit debit cardholder s primary identification number is NUMBER missing for this transaction MISSING This information is not used for DMERC 11124 ADD NAME N2 The segment containing additional name information for the INFO MISSING credit debit cardholder is missing This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 192 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 11125 ADD REFO1 The qualifier for the credit debit cardholder s secondary CREDIT DEBIT identification number information for this transaction is ID QUAL invalid INVALID Valid Values AB Acceptable Source Purchaser ID BB Authorization Number This information is not used for DMERC 11126 AUTHORIZATI REFO2 The secondary identification number for the credit debit ON NUMBER cardholder is missing MISSING This information is not used for DMERC 11127 CREDIT DEBIT AMTO2 The val
152. TPO3 The last certification date date CMN was signed by the DATE FUTURE physician entered is invalid for this line When entered this DATE information must not be greater than today s date 10671 ORDER DT DTP The segment providing the order date for this line exceeds EXC MAX USE maximum use When this information is reported only 1 occurrence per line may be used This information is not used for DMERC 10672 NOT USED 10673 DTE TIME PER DTP02 The qualifier indicating the format used to report the order FORMAT date for this line is invalid QUALIFIER INVALID Valid Value D8 Date expressed in format CCYYMMDD This information is not used for DMERC 10674 ORDER DATE DTPO3 The order date entered is invalid for this line When entered INVALID this information must be entered in a CCYYMMDD format This information is not used for DMERC 10675 ORDER DATE DTPO3 The order date entered is invalid for this line When entered FUTURE DATE this information must not be greater than today s date This information is not used for DMERC 10676 DTE LAST DTP The segment providing the date last seen for this line SEEN DT EXC exceeds maximum use When this information is reported MAX USE only 1 occurrence per line may be used This information is not used for DMERC 10677 NOT USED 10678 DTE TIME PER DTP02 The qualifier indicating the format used to report the date FORMAT last seen for this line is invalid QUALIFIER INVALID Valid Value D8 Date expres
153. This information is not used for DMERC 10184 ADD PAT ID REF The segment containing additional patient when other than SEGMENT EXC subscriber identification information exceeds maximum use MAX USE When this information is reported only 5 occurrences per claim may be used This information is not used for DMERC 10185 PAT ID 2 REFO1 The qualifier for the patient s when other than subscriber INVALID secondary identification number information for this claim is invalid Valid Values 1W Member identification number 23 Client number IG Insurance policy number SY Social Security Number This information is not used for DMERC 10186 PAT ID 2 REF02 The secondary ID for this patient when other than subscriber MISSING is missing for this patient This information is not used for DMERC 10187 INVALID CLM CLM11 The related causes code is invalid for this claim 11 VALUE Valid Values AA Auto Accident EM Employment OA Other Accident 10188 CLM CLM The segment containing claim information is missing Each SEGMENT DMERC claim must contain a CLM segment If over 100 MISSING claims are to be submitted contact your software vendor for instruction 10189 TOTAL CLAIM CLMO1 The value entered to indicate the total claim charge is CHARGE invalid The amount entered must contain numeric values AMOUNT NOT only NUMERIC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 35 Edit E
154. This information is not used for DMERC 10286 ADMISSION DT DTP The segment providing the date of admission for this claim SEG EXC MAX exceeds maximum use If this information is reported only 1 USE occurrence per claim may be used This information is not used for DMERC 10287 NOT USED 10288 ADMISSION DT DTP02 The qualifier indicating the format used to report the FMT Q INVALID admission date for this claim is invalid Valid Value D8 Date expressed in format CCYYMMD This information is not used for DMERC 10289 ADMISSION DT DTP03 The hospitalization admission date entered is invalid for this INVALID FMT claim When entered this information must be entered in a CCYYMMDD format This information is not used for DMERC 10290 ADMISSION DT DTP03 The hospitalization admission date entered is invalid for this FUTURE DT claim When entered this information must not be greater than today s date This information is not used for DMERC 10291 DISCHARGE DTP The segment providing the date of discharge for this claim DT SEG EXC exceeds maximum use If this information is reported only 1 MAX USE occurrence per claim may be used This information is not used for DMERC 10292 NOT USED Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 49 Edit Edit Description Element Edit Explanation Number Segment ID 10293 DISCHARGE DTP02 The qualifier indicating the format used to report the D
155. VICES procedure code submitted If the procedure code submitted is INVALID a capped rental item the unit of service must be equal to one unless the procedure code has both the RT and LT modifiers appended In that instance the unit of service may be equal to two 40024 CMN CR3 You have indicated there is a CMN included with this claim INFORMATION however the segment containing the durable medical MISSING equipment certification did not accompany this claim www cignamedicare com edi Revised April 2003 Page 4 Front End Edits DMERC Edit EDIT Element Edit Explanation Number DESCRIPTION ID 40025 CMN LENGTH OF CR303 The length of need reported on the durable medical NEED INVALID equipment CMN is invalid Verify the length of need was reported as numeric data and does not equal all zeros 40026 OXYGEN CMN CR5 You have indicated there is a CMN included with this claim INFORMATION however the segment containing the oxygen certification MISSING form did not accompany this claim 40027 OXYGEN CMN CR502 The length of need reported on the oxygen certification form LENGTH OF is invalid Verify the length of need was reported as numeric NEED INVALID data and does not equal all zeros or is greater than 100 40028 ABG RESULTS CR510 The value entered as the arterial blood gas test result INVALID question 1A on the oxygen certification form is not numeric 40029 OXIMETRY CR511 The va
156. Valid Values N No X rays are not maintained and available for carrier review Y Yes X rays are maintained and available for carrier review This information is not used for DMERC 10368 AMBO CERT CRC The segment containing ambulance certification information SEG EXC MAX exceeds maximum use If this information is reported only 3 USE occurrences per claim may be used This information is not used for DMERC 10369 CLAIM CRCO1 The code used to indicate the type of certification that is INFORMATION being sent with this claim is invalid QUAL INVALID Valid Values 07 Ambulance certification 75 Functional limitations E1 Spectacle lenses E2 Contact lenses E3 Spectacle frames This information is not used for DMERC 10370 AMBO CERT CRC02 The ambulance certification condition code indicator is COND CODE invalid for this claim INVALID Valid Values N No Y Yes This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 62 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10371 AMBO CERT CRC03 The code indicating the patient s condition is invalid for this COND REAS 1 ambulance claim INVALID Valid Values 01 Patient was admitted to a hospital 02 Patient was bed confined before the ambulance service 03 Patient was bed confined after the ambulance service 04 Patient was moved by stretcher 05 Patient was unconsc
157. Verify the date entered is greater than the subscriber s date INVALID of birth and the date is not greater than today s date 40002 PATIENT WEIGHT PATO8 The amount entered as the subscriber s weight is invalid INVALID Verify the value entered is numeric 40003 PATIENT WEIGHT PATO8 The amount entered as the subscriber s weight equals less INVALID than 1 pound 40004 NOT USED 40005 PATIENT ZIP N403 The zip code indicated for the subscriber s address was CODE INVALID reported in an invalid format Verify the zip code contains only numeric data and is not all zeros or all nines and is either five or nine digits in length 40007 PATIENT WEIGHT PATO8 The amount entered as the patient s weight is invalid Verify INVALID the value entered is numeric and is greater than 0 This information should only be reported if the patient is not the same as the subscriber 40008 PATIENT WEIGHT PATO8 The amount entered as the patient s weight equals less than INVALID 1 pound This information should only be reported if the patient is not the same as the subscriber 40009 INSURED STATE N402 The state abbreviation for the patient state is not a valid two CODE INVALID character state abbreviation code This information should only be reported if the patient is not the same as the subscriber 40010 INSURED ZIP N403 The zip code indicated for the patient s address was reported CODE INVALID in an invalid format Verify the zip code contains only numeric
158. X Facsimile TE Telephone This information is not used for DMERC 10523 CLM ADJ DATE DTP The segment providing the other payer claim adjudication EXC MAX USE date for this claim exceeds maximum use If this information is reported only 1 occurrence per claim may be used This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare www cignamedicare com edi Revised April 2003 Page 98 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10524 DATE TIME DTPO1 The qualifier for the date claim paid for this claim is invalid QUALIFIER INVALID This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare Valid Value 573 Date claim paid 10525 DATE TIME DTP02 The qualifier indicating the format used to report the date the PER FORMAT claim was paid is invalid QUALIFIER INVALID This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare Valid Value D8 Date expressed in format CCYYMMDD 10526 ADJUD PYMT DTP03 The date claim paid entered is invalid for this claim When DT INVALID entered this information must be entered in a valid CCYYMMDD
159. acter followed by 8 numeric characters e Telephone number you have on file with the EDI Department Region D DMERC EDI Manual Revised June 2002 Stratus Network User Guide Page 3 Connection Requirements The following information describes the settings to setup your communications software All users of the Stratus Network must have their own communications software i e HyperTerminal ProComm Plus pe Anywhere that will support X Modem 1 K X Modem Y Modem Z Modem or Kermit protocols For information on setting up HyperTerminal ProComm Plus and pe Anywhere please see page 4 X Modem 1K X Modem Y Modem Z Modem Kermit ee Se CIGNA Medicare recommends using the Z modem Initial Password FIRST Note The User ID Number and Initial Password are assigned by CIGNA Medicare Both the User ID Number and Password are case sensitive Use upper lowercase characters as shown www cignamedicare con edi Revised June 2002 Page 4 Chapter Five Dial Up Setup We have included instructions for the communication packages that we support These are general instructions If you are not using one of the software packages listed below or need detailed information regarding these software packages please contact the manufacturer of the software or refer to the user s manual that came with the software HyperTerminal Windows 95 98 and NT 4 0 1 2 6 Open HyperTerminal Click Start and then point to Programs Click A
160. actic series is SERIES TOTAL missing MISSING This information is not used for DMERC 11096 TREATMENT CR206 The time period involved in this chiropractic treatment series PERIOD is missing COUNT MISSING This information is not used for DMERC 11097 MONTHLY CR207 The number of chiropractic treatments rendered in the TREATMENT month of service is missing COUNT MISSING This information is not used for DMERC 11098 MEDICAL CR303 The value indicating the length of need for this line item is NECESSITY missing on this CMN LENGTH MISSING 11099 MEDICAL CR502 The value indicating the length of need for oxygen therapy is NECESSITY missing on the oxygen certification form LENGTH MISSING Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 189 Edit Edit Description Element Edit Explanation Number Segment ID 11100 ANESTH QTY02 The value representing the anesthesia modifying units is MODIFYING missing on this line UNITS MISSING This information is not used for DMERC 11101 TEST RESULT MEA03 The value indicating the results of the oxygen saturation test VALUE or ABG test or the patient s height is missing from the CMN MISSING 11102 ALLOW HCP02 The allowed amount by the repricer of this line is missing AMOUNT PRICING This information is not used for DMERC MISSING 11103 NOT USED 11104 CONTRACT CN103 The value entered as the contract percentage amount EX
161. adjudicated this claim prior to being submitted to Medicare 10958 COB AMT02 The value representing the primary payer s covered amount COVERED exceeds two positions to the right of the decimal point AMT CANNOT HAVE gt 2 DEC This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10959 COB AMT02 The value representing the primary payer s discount amount DISCOUNT exceeds 18 positions AMT EXCEEDS MAXIMUM This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10960 COB AMT02 The value representing the primary payer s discount amount DISCOUNT exceeds two positions to the right of the decimal point AMT CANNOT HAVE gt 2 DEC This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10961 COB DAILY AMT02 The value representing the primary payer s per day limit LIMIT AMT amount exceeds 18 positions EXCEEDS MAXIMUM This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10962 COB DAILY AMT02 The value representing the primary payer s per day limit LIMIT AMT amount exceeds two positions to the right
162. age in the DMERC Region D Supplier Manual 20115 PROCEDURE SV101 5 The third modifier appended to the HCPCS code for MODIFIER3 INVALID this line is invalid Verify correct modifier usage in the DMERC Region D Supplier Manual 20116 PROCEDURE SV101 5 The third modifier and HCPCS code combination MODIFIER3 INVALID reported for this line item is invalid Verify the correct modifier usage in the DMERC Region D Supplier Manual 20117 PROCEDURE SV101 6 The fourth modifier appended to the HCPCS code for MODIFIER4 INVALID this line is invalid Verify correct modifier usage in the DMERC Region D Supplier Manual 20118 PROCEDURE SV101 6 The fourth modifier and HCPCS code combination MODIFIER4 INVALID reported for this line item is invalid Verify the correct modifier usage in the DMERC Region D Supplier Manual 20119 LINE ITEM CHANGE SV102 The charge submitted for this line item is invalid Verify AMOUNT INVALID the charge was entered correctly and is not all zeros 20120 DIAGNOSIS CODE SV107 1 The diagnosis code pointer for this line item is invalid POINTER 1 INVALID Valid Values 1 2 3 4 www cignamedicare com edi Revised April 2003 Page 20 Chapter Eight Edit Number EDIT DESCRIPTION ElementID Edit Explanation 20121 DIAGNOSIS CODE V107 2 The diagnosis code pointer for this line item is invalid POINTER 2 INVALID Valid Values 1 2 3 4 20122 DIAGNOSIS CODE V107 3 The diagnosis code pointer for th
163. agnosis on the INVALID claim Valid Values 1 2 3 4 5 6 7 8 10590 DIAG CODE V107 2 The second diagnosis code pointer for this line item is POINTER invalid Use this code to point back to any secondary INVALID diagnosis on the claim Valid Values 1 2 3 4 5 6 7 8 10591 DIAG CODE V107 3 The third diagnosis code pointer for this line item is invalid POINTER Use this code to point back to any secondary diagnosis on INVALID the claim Valid Values ON DOO RAON Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 113 Edit Edit Description Element Edit Explanation Number Segment ID 10592 DIAG CODE V107 4 The fourth diagnosis code pointer for this line item is invalid POINTER Use this code to point back to any secondary diagnosis on INVALID the claim Valid Values 1 2 3 4 5 6 7 8 10593 EMERG IND SV109 The qualifier indicating emergency services for this line is INVALID invalid Valid Values N No Y Yes 10594 EPSDT IND SV111 The qualifier indicating EPSDT services is invalid for this INVALID line Valid Values Y Yes N No This information is not used for DMERC 10595 FAMILY PLAN SV112 The qualifier indicating family planning services is invalid for IND INVALID this line Valid Values Y Yes N No This information is not used for DMERC 10596 CO PAY STAT SV115 The qualifier indicting co pay exemption status is invalid for INVALID this li
164. ain accurate records both electronically and in your paper files It is mandatory that you retain all original source documents for seven years In the event of an audit you will be requested to provide original documentation and it must be accessible As a service to our electronic billers EDI reviews are conducted periodically to ensure that you are maintaining accurate records EDI reviews are conducted by our employees via telephone at your place of business or at CIGNA Medicare An EDI review may either be an initial or a subsequent review In an initial review your company may randomly be selected for an EDI review An initial review will be conducted before you transmit electronic claims An initial review will e Ensure the validity of procedure and diagnosis codes e Verify the satisfactory completion of source documents that reflect actual equipment supplies delivered e Determine whether EDI Enrollment Forms have been properly completed and returned You may not transmit electronic claims without completing the EDI Enrollment Form e Discuss and resolve any problems prior to the first electronic claim transmission Once you have begun transmitting electronic claims CIGNA Medicare may also perform a subsequent review You will be notified in advance of this review and of the specific claims we will be reviewing A subsequent review will e Verify that patient signatures are being obtained in the appropriate manner e Verify that the
165. alid for this claim When entered this information must be entered in a valid CCYYMMDD format 10103 SUBSCRIBER DATE OF DEATH FUTURE DATE PATO6 The patient s date of death entered is invalid for this claim When entered this information must not be greater than today s date Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 23 Edit Edit Description Element Edit Explanation Number Segment ID 10104 SUBSCRIBER PATO7 The code used to indicate the measurement of the patient s WEIGHT MEA weight is invalid for this claim This is used to report the QUAL INVALID subscriber s weight on DMERC CMN forms 2 03 and10 02 Valid Value GR Grams 10105 SUBSCRIBER PAT08 The patient s weight is missing for this claim This WEIGHT information is required when reporting patient s weight for MISSING DMERC CMN forms 2 03 and 10 02 10106 SUBSCRIBER PATO9 The pregnancy indicator is invalid for this claim PREG IND CODE INVALID Valid Value Y Indicating Patient is pregnant This information is not used for DMERC 10107 SUBSCRIBER NM1 The segment providing name information for the subscriber NAME of this claim is missing This information is required on all SEGMENT DMERC transactions MISSING 10108 SUBSCRIBER NM101 The qualifier identifying the subscriber for this transaction is NAME QUAL invalid INVALID Valid Value IL Insured or subscriber 10109 SUBSCRI
166. alifier indicating the format used to report the begin FORMAT therapy CMN initial date date for this line is invalid QUALIFIER INVALID Valid Value D8 Date expressed in format CCYYMMDD 10664 BEG THERAPY DTP03 The begin therapy CMN initial date date entered is invalid DATE INVALID for this line When entered this information must be entered in a CCYYMMDD format 10665 BEG THERAPY DTP03 The begin therapy CMN initial date date entered is invalid DATE FUTURE for this line When entered this information must not be DATE greater than today s date 10666 LAST CERT DT DTP The segment providing the last certification date date the EXC MAX USE CMN was signed for this line exceeds maximum use When this information is reported only 1 occurrence per line may be used 10667 NOT USED 10668 DTE TIME PER DTP02 The qualifier indicating the format used to report the last FORMAT certification date date CMN was signed by the physician for QUALIFIER this line is invalid INVALID Valid Value D8 Date expressed in format CCYYMMDD 10669 LAST CERT DTPO3 The last certification date date CMN was signed by the DATE INVALID physician entered is invalid for this line When entered this information must be entered in a CCYYMMDD format www cignamedicare com edi Revised April 2003 Page 128 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10670 LAST CERT D
167. another payer adjudicated this claim prior to being submitted to Medicare This information is not used for DMERC 11050 ADJ AMOUNT CAS15 The value entered as the line adjustment amount is invalid CANNOT HAVE If reported this amount cannot exceed two positions to the gt 2DEC right of the decimal point PLACES This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare This information is not used for DMERC 11051 ADJUSTED CAS16 The value entered as the line level adjusted units of service UNITS amount is invalid If reported this amount cannot exceed 15 EXCEEDS positions MAXIMUM This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 11052 ADJ UNITS CAS16 The value entered as the line level adjusted units of service EXCEEDS MAX amount is invalid If reported do not exceed the maximum DECIMAL number of positions to the right of the decimal point PLACES This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 11053 ADJ AMOUNT CAS18 The value entered as the line level adjusted amount is EXCEEDS invalid If reported this amount cannot exceed 18 positions MAXIMUM This information is used for Medicare
168. at and should be resolved VERS by contacting your software vendor This information is not used for DMERC 11170 SUBLUX LVL CR204 The subluxation level code included with this claim is invalid CODE 2 NOT USED IN X12 This edit indicates an invalid format and should be resolved VERS by contacting your software vendor This information is not used for DMERC 11171 CHIRO TREAT CR205 The unit or basis for measurement code with this claim is TIME QUAL invalid NOT USED X12 VERS This edit indicates an invalid format and should be resolved by contacting your software vendor This information is not used for DMERC 11172 TREAT CR206 The treatment period count included for this claim is invalid PERIOD COUNT NOT This edit indicates an invalid format and should be resolved USED IN X12 by contacting your software vendor VERS This information is not used for DMERC 11173 MO NBR CR207 The monthly treatment count included with this claim is CHIRO TREAT invalid NOT USED IN X12 VERS This edit indicates an invalid format and should be resolved by contacting your software vendor This information is not used for DMERC 11174 CHIRO COMPL CR209 The complication indicator included with this claim is invalid CODE NOT USED IN X12 This edit indicates and invalid format and should be resolved VERS by contacting your software vendor This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 199
169. at this time 11116 SERVICE LINE SV1 The service line for this claim is missing A claim line is INFORMATION required for every DMERC claim SEG MISSING 11117 LX NOT LX The line items submitted in this file were not correctly INCREMENTE sequenced If this error is received please contact your D BY 1 software vendor 11118 CREDIT DEBIT NM101 The qualifier identifying the credit or debit cardholder s name CRDHOLDER for this transaction is invalid NAME QUAL INVALID Valid Values AO Account of This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 191 Edit Edit Description Element Edit Explanation Number Segment ID 11119 CREDIT DEBIT NM102 The qualifier identifying the credit debit cardholder type is NAME invalid for this transaction QUALIFIER INVALID Valid Values 1 Person 2 Non Person entity This information is not used for DMERC 11120 CREDIT DEBIT NM103 The last name or organization name is missing for this LAST ORG transaction If you have identified the credit debit cardholder NAME to be a person this element must contain the last name of MISSING that person If you have identified the credit debit cardholder to be a non person entity this element must contain the company name This information is not used for DMERC 11121 CREDIT DEBIT NM104 The first name of the credit debit cardholder is missing for FIRS
170. ation from one computer to another D DMERC Medicare Automated Claims System DMACS32 Software The computer software provided by CIGNA Medicare that allows suppliers to create Medicare claim files Note DMACS32 is a stand alone program and cannot be integrated with any existing medical management software program a Electronic Data Interchange EDI The computer to computer electronic exchange of business documents using standard formats EDI Enrollment Form A HCFA now CMS agreement stating that the provider supplier is responsible for the Medicare claims sent by itself its employees or its agents Each provider of health care services physician or supplier that intends to submit electronic media claims EMC must execute the agreement The EDI Enrollment Form must be completed prior to submitting EMC to Medicare The signed original form must be on file for each Medicare carrier that processes your claims before production claims may be transmitted Electronic Funds Transfer EFT Automatically transferring payment to a provider s or supplier s bank account Electronic Media Claims EMC Transmitting claims by computer rather than submitting them on paper Electronic Receipt Listing ERL and Standardized Error Report A report that lists all claims received by CIGNA Medicare The standardized error report will list all of the claims that were rejected and did not get into the system Electronic Remittance Notice ERN An
171. ation on beneficiary eligibility dates and deductible information MCM 3021 5 3021 7 Process The process begins by creating a file that contains the following beneficiary information This file is sent to CIGNA Medicare via the Stratus Network e Beneficiary s ID number your account number e Beneficiary s Health Insurance Claim Number HICN e A portion of the beneficiary s name e The sex of the beneficiary Approximately 48 hours later CIGNA Medicare will return a response file containing the following information on the beneficiary e Beneficiary s Medicare Part B eligibility entitlement date e Medicare Part B termination date if applicable e Current year deductible information e HMO information if applicable Requirements To take advantage of this option you must have a software program that creates the Beneficiary Eligibility upload request file and reads the return response file Beneficiary Eligibility software may be purchased from a software vendor The EDI Department does not supply Beneficiary Eligibility software If you would like to program your own software please contact the EDI Department Once you have obtained your software you will need to apply for Beneficiary Eligibility The following are the necessary steps to apply 1 Complete the DMERC EDI Customer Profile form and select Beneficiary Eligibility as an additional feature This form is located in the Appendix of this manual It is also
172. attached to your modem Enrolling in CSI The following are the necessary steps for enrolling in CSI 1 Complete the DMERC EDI Customer Profile form and select CSI as an additional feature This form is located in the Appendix of this manual It is also available through the EDI Web site section located at www cignamedicare com edi 2 Return completed form to CIGNA Medicare along with a 25 check for AT amp T Passport for Windows software 3 Upon receipt CIGNA Medicare will process your request and mail your CSI Manual your RCD number and the AT amp T Passport for Windows communications software Note Please allow 10 21 business days for processing 4 Sign and return the AT amp T Global Network Services Limited Service User s Agreement to AT amp T A copy of this agreement is located in the CSI Manual 5 Upon receipt of the signed agreement AT amp T will issue you an AT amp T account and User ID 6 Once you receive your AT amp T account and User ID you are ready to use CSI Region D DMERC EDI Manual November 2001 EDI Products and Services Page 3 Electronic Remittance Notices An Electronic Remittance Notice ERN is an electronic data file that shows claims that have been paid and the dollar amounts for each claim MCM 3023 2 In addition it shows claims denied with the reason for denial This file is the same as the Provider Remittance Notices suppliers receive through the mail You will be given the option of receivin
173. available through the EDI Web site section located at www cignamedicare com edi 2 Return completed form to CIGNA Medicare 3 Upon receipt CIGNA Medicare will process your request and mail you a Beneficiary Eligibility Manual Note Please allow 10 21 business days for processing Privacy Act According to guidelines set by the Centers for Medicare and Medicaid Services CMS Beneficiary Eligibility will allow only Medicare participating Part B physicians and suppliers and their authorized billing agents automated access to beneficiary eligibility data as long as the provider bills electronically in the National Standard Format NSF or the ANSI X12 837 Transaction Set Disclosure of Medicare eligibility data is restricted under the provisions of the Privacy Act of 1974 Under limited circumstances the Privacy Act permits us to disclose information without prior written consent of the individual to whom the information pertains one of these is for routine uses that is disclosure for purposes that are compatible with the purpose for which we collect the information In the case of Part B provider access a routine use exists which permits release of data to providers and or their authorized billing agents for the purpose of preparing an accurate claim Region D DMERC EDI Manual November 2001 Chapter Three EDI Reviews CIGNA Medicare may conduct an EDI review on your company MCM 5240 It is important that you maint
174. aximum use When this information USE is reported only 1 occurrence per transaction may be used 10449 SER FAC LOC N4 The segment providing city state and zip code information C S Z MISSING for the service facility location for this transaction is missing When reporting address information the city state and zip code information must be included Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 79 Edit Edit Description Element Edit Explanation Number Segment ID 10450 LAB FAC CITY N401 The service facility location city is missing for this claim MISSING When reporting address information the city state and zip code information must be included 10451 LAB FAC N402 The service facility location state abbreviation is missing for STATE this claim When reporting address information the city MISSING state and zip code information must be included 10452 LAB FAC ZIP N403 The service facility location zip code is missing for this claim MISSING When reporting address information the city state and zip code information must be included 10453 SER FAC LOC REF The segment containing additional service facility location SEC ID EXC identification information exceeds maximum use When this MAX USE information is reported only 5 occurrences per claim may be used 10454 REF ID REFO1 The qualifier for the facility secondary identification number QUALIFIER information fo
175. billing electronically is the opportunity to sign up for additional EDI products and services Chapter 2 provides detailed explanations and specific requirements for each of the additional EDI products and services such as Claim Status Inquiry CSD Electronic Remittance Notices ERNs and Beneficiary Eligibility Chapter 3 describes the two types of EDI reviews that may be conducted by CIGNA Medicare We will conduct EDI reviews periodically to ensure that the necessary source documents are being maintained and that the guidelines for submitting electronic claims are being followed New electronic billers must test their software compatibility before they are approved to transmit production claims Chapter 4 of this manual describes the testing process and identifies the requirements for passing successfully There is also a list of common questions and answers regarding the testing process Chapter 5 contains the Stratus Network User Guide You will find step by step instructions on transmitting claims from start to finish including how to download reports such as the Functional Acknowledgement report 997 and the Electronic Report Package Information on electronic reports may be found in Chapter 6 which includes sample reports with descriptions Transmitted claims are checked against three levels of front end edits to make sure the claims are complete and correct If there are errors detected on the transmitted claims then the claim will not
176. billing provider PROV ID identification information exceeds maximum use When this SEGMENT EXC information is reported only 8 occurrences per transaction MAX USE may be used 10069 CREDIT DEBIT REFO1 The qualifier for the credit debit card secondary identification QUAL INVALID number is invalid for this transaction Valid Values 06 System Number 8U Bank Assigned Security Identifier EM Electronic Payment Reference Number IJ Standard Industry Classification SIC code LU Location Number RB Rate code number ST Store Number TT Terminal Code This information is not used for DMERC 10070 CREDIT DEBIT REF02 The secondary identification number for the credit debit SEC ID cardholder information is missing for this transaction MISSING This information is not used for DMERC 10072 BILL PROV PER The segment containing billing provider contact information CONTACT exceeds maximum use When this information is reported INFO SEG EXC only 2 occurrences per transaction may be used MAX USE 10073 BILL PROV PERO1 The qualifier for the billing provider contact information for CONTACT this transaction is invalid for this transaction QUAL INVALID Valid Value IC Information contact www cignamedicare com edi Revised April 2003 Page 16 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10074 BILL PROV PER02 The billing provider contact person s nam
177. ble PARTY ZIP CODE party s address was reported in an invalid format Verify INVALID the zip code contains only numeric data and is not all zeros or all nines and is either five or nine digits in length 20047 RESPONSIBLE N404 The country code indicated on this claim for the PARTY COUNTRY responsible party s address is not a valid country code CODE INVALID 20048 PATIENT WEIGHT PAT08 The amount entered for the patient when other than INVALID the subscriber weight is invalid This information is not used for DMERC 20049 PATIENT STATE N402 The state abbreviation indicated on this claim for the CODE INVALID patient is not a valid two character state abbreviation code www cignamedicare com edi Revised April 2003 Page 8 Chapter Eight Edit Number EDIT DESCRIPTION ElementID Edit Explanation 20050 PATIENT COUNTRY N404 The country code indicated on this claim for the CODE INVALID patient s address is not a valid country code 20051 TOTAL CLAIM CLM02 The total claim charge amount is invalid Verify the sum CHARGE AMOUNT of all line item charges equal the total claim charge INVALID submitted with this claim 20052 CLAIM FREQUENCY CLM05 3 The type of claim being sent is invalid TYPE CODE INVALID Valid Values 1 Original 7 Replacement 20053 AUTO ACCIDENT CLM11 4 The state abbreviation indicated on this claim for the STATE CODE auto accident state is not a valid two c
178. brief overview of the various benefits of billing electronically Faster payment Billing electronically cuts the disbursement time in half and improves cash flow The payment floor for clean paper claims is 26 days which means that on the 27 day if it is a clean claim you will be eligible to receive payment A clean claim is one which does not require you to investigate or develop outside your Medicare operation on a pre payment basis MCM 5240 11 1A Whereas with electronic claims the payment floor is 13 days which means that on the 14 day a clean claim will be eligible to receive payment Simply put by transmitting electronically your Medicare payments are processed and mailed out 13 days faster than submitting on paper Increased tracking capabilities and increased control over the billing process Electronic billing allows more tracking methods than paper billing which gives you more control over the billing process With electronic billing claims can be tracked in the following ways Online receipt verification After transmitting your claims to us you will receive automatic verification that the transmission was successful Although the confirmation will not give you details about your claims it will acknowledge receipt of that file The number of claims received and the total dollar value of the claims transmitted may also be verified MCM 3023 2 Electronic reports Within two days of a successful transmission you
179. cally The information contained on this report includes e Claim sequence number Position of this claim in relation to the total received claims from this submitter for the run date listed on this report e Patient account number e Total lines This number represents the total number of lines submitted on this claim e Earliest from date This date represents the earliest service from date reported on all lines of the claim e Latest to date This date represents the latest service to date reported on all lines of the claim e Total billed amount This is the total dollar amount as reported on the claim e LN This column represents the line on which the error occurred For example if a six line claim is submitted with an invalid date of service reported on line three causing the claim to reject the value in LN would be 03 e Edit number This is a five digit number that represents the reason why the claim was rejected e Edit description This is a description provided to help you quickly identify the cause of the error e Actual submitted data The actual claim data entered by the submitter is shown under the edit number This is beneficial for helping identify at a glance what may have caused the error to occur For example it is possible that the letter O was keyed instead of the number 0 e Implementation Guide references The information presented on the right hand side of
180. cannot MAXIMUM exceed 15 positions This information is not used by DMERC 11028 VALUE HCP12 The value entered as the pricing repricing approved units or CANNOT inpatient days is invalid If reported this amount cannot CONTAIN contain a decimal point DECIMAL This information is not used by DMERC 11029 SVC LINE PD SVD02 The value entered as the line adjudication service line paid AMT EXCEEDS amount is invalid If reported this amount cannot exceed 18 MAXIMUM positions This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 11030 SVC LINE PD SVD02 The value entered as the line adjudication service line paid AMT CANNOT amount is invalid If reported this amount cannot exceed two HAVE gt 2 DEC positions to the right of the decimal point This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 11031 PD SVC CTN SVD05 The value entered as the line adjudication information paid EXCEEDS service unit count amount is invalid If reported this amount MAXIMUM cannot exceed 15 positions This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare www cignamedicare com edi Revised April 2003
181. ccessories click Communications this may or may not be a step depending on which version of Windows is installed and then click HyperTerminal When the subfolder opens click on HyperTerminal In the Connection Description dialog box type Stratus Network in the Name field and select an icon Click OK This will take you to the Connect To dialog box In the Area code field type 860 In the Phone number field type 602 0000 Click OK This will open the Connect dialog box Click on Modify and make sure there is a checkmark in the box next to Use country region code when dialing this number Click the Settings button and change the emulation to VT100 Click OK to save your changes To connect to the Stratus Network click Dial in the Connect dialog box Exit the program when you are finished You will be prompted to save your settings ProComm Plus 1 T 8 Click Start and then point to Programs Click on ProComm Plus When the subfolder opens click on ProComm Plus On the File menu click Connection Directory On the Connection menu click New Entry This will display the Add Directory Entry dialog box On the Data tab type Stratus Network in the Name field Type 860 in the Area Code field and 602 0000 in the Data Number field Click OK Make sure you are on the Data tab of the Connection Directory dialog box Click on Stratus Network in the Entries field Click Basic Options an
182. ck Other Dezenption of 27 hes rene Chome the program you went to use NODECFGE T Alweys use the program to ogen this He ck Cancel Dither www cignamedicare con vedi Revised June 2002 Page 22 Chapter Five List File Names This option allows you to see a list of your files available to download as well as files you have recently uploaded 1 To see a list of your files type 3 and press Enter kkkkkkkkkkekeeeee Mailbox Access Facility tkkkkkekkkkkeekeeeee User Id MBOO1A Set User Defaults Current Settings Change Data Type Number of Files DATA TYPE SEND_ANSITEST List file names MAILBOX SD_CATI INBOUND View a file PROTOCOL PROMPT Upload Put a file in Mailbox FILE TYPE STREAM Display Activity Log PRINTER_PAUSE INITIAL MENU OPT Return to main menu Network 7 ENTER YOUR SELECTION 3 2 The following screen will appear giving a short description for filename suffixes that appear on your files Pa poe ar arp Pe ek a ee Filename SUFFIXES ee wop File was ALREADY processed bk Back version of a file SpE File contains partial info CEL File transmission failed save File under retention management bad File contains bad data PUREE ES E NE E E A ENS ONEA NE E OR NS E E BE Ae ee ESO Please enter the MASK for the files you wish to list press lt RETURN gt to list all files or for masking examples ENTER YOUR SELECTIO
183. currence per line may be used This information is not used for DMERC 10761 NOT USED 10762 APPROV AMT AMT The segment providing the primary payer approved amount EXC MAX USE exceeds maximum use If this information is reported only 1 occurrence per line may be used This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10763 NOT USED 10764 PSTAGE AMT The segment providing the postage amount exceeds CLMED AMT maximum use for this line If this information is reported EXC MAX USE only 1 occurrence per line may be used This information is not used for DMERC 10765 NOT USED Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 139 Edit Edit Description Element Edit Explanation Number Segment ID 10766 LINE NOTE NTE The segment providing additional narrative information for EXC MAX USE this line exceeds maximum use When this information is reported only 1 occurrence per line may be used 10767 NOTE REF NTEO1 The qualifier identifying the type of additional narrative INVALID information being sent with this line is invalid Valid Values ADD Additional information DCP Goals rehabilitation potential or discharge plans PMT Payment TPO Third party organization notes 10768 QUANTITY HSDO1 The qualifier specifying the type of services being reported QUALIFIER f
184. d This information is not used for DMERC 10425 ENTITY ID NM101 The qualifier identifying the rendering provider for this claim CODE QUAL is invalid INVALID Valid Value 82 Rendering provider This information is not used for DMERC 10426 ENTITY TYPE NM102 The qualifier identifying the rendering provider type is invalid QUALIFIER for this claim INVALID Valid Values 1 Person 2 Non person entity This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 75 Edit Edit Description Element Edit Explanation Number Segment ID 10427 REND PROV NM103 The last name or company name is missing for this claim If LAST OR ORG you have specified the rendering provider type to be a NAME person this element must contain the last name of that MISSING person If the rendering provider was identified as a non person entity this element must contain the company name This information is not used for DMERC 10428 REND PROV NM104 The first name of the rendering provider is missing for this FIRST NAME claim If you have specified the rendering provider type to be MISSING a person this element must contain the first name of that person If the rendering provider was identified as a non person entity this element is not used This information is not used for DMERC 10429 ID CODE NM108 The qualifier identifying the rendering provider identification QUALIF
185. d a break in medical necessity of at least 60 days plus whatever days remain in the rental month during which the need for oxygen ended the supplier should obtain a new initial CMN An explanation is needed to document this change in medical condition stating why a new medical need is being established This CMN would need to be submitted on paper with the documentation for the break of medical necessity In this case the CMN cannot be transmitted electronically The recertification or revised CMN transmitted electronically has a recertification or revised date that is prior to or the same as the recertification or revised date on the CMN on file for this procedure code for this beneficiary This error most often occurs when duplicate recertification or revised CMNs are transmitted or when recertification or revised CMNs are transmitted out of order For example The Enteral Company transmits a revised CMN with an 08 01 00 date for procedure code B4150 enteral formula The CMN is transmitted electronically and posted to CIGNA Medicare s CMN files Then a day or more later The Enteral Company realizes they have a revised CMN with a date of 07 01 00 for B4150 The Enteral Company transmits the revised CMN for 07 01 00 This CMN rejects with edit 3032 because CIGNA Medicare has already posted the CMN with the revised date of 08 01 00 Resolution Make sure CMNs are transmitted in sequence If you receive this error and the claim was processe
186. d an Electronic Report Package or to see if your files were uploaded successfully You can access the activity log online anytime you are connected to the Stratus Network 1 From the Mailbox Access Facility menu type 7 and press Enter Kkkkkekkekkeeeeeee Mailbox Access Facility Kkkkkkkekkekekeekee User Id MBOO1A Set User Defaults Current Settings Change Data Type Number of Files DATA TYPE RECEIVE ANSITEST List file names MAILBOX ND_XATO OUTBOUND View a file Download Get a file from Mailbox PROTOCOL PROMPT FILE TYPE STREAM Display Activity Log PRINTER_PAUSE INITIAL MENU OPT Return to main menu Fer Network ENTER YOUR SELECTION 7 2 The activity log screen will appear The time and date of your login and logout will be listed In addition each transmission that was attempted completed or aborted will be listed in the log 3 You can view additional screens by pressing Enter 4 To return to the Mailbox Access Facility menu type q and press Enter PUD 2000 10 09 09 48 59 DOWNLOAD END COMPLETED SUCCESSFULLY 2000 10 09 09 49 13 DOWNLOAD START gt FXF_7 gt fxf gt ND_XATO gt MO01A0 2000 09 21 11 21 13 7 2000 10 09 09 51 16 DOWNLOAD END Attempt ABORTED Transfer cancelled by us ter 2000 10 09 09 51 36 LOGOUT ASYNC telnet_ew 10 MBOO1A 2000 10 09 09 58 47 LOGIN ASYNC telnet_ew 25 MBOO1A 2000 10 09 09 58 59 DOWNLOAD START gt FXF_7 gt fxf gt ND_XATO gt MO01A0_ 2000 09 21 11 21
187. d and paid incorrectly due to the wrong CMN for that date of service request a review If the claim was processed and payment was not made submit the claim and recertification or revised CMN to Nashville on paper for processing CMNs cannot be transmitted electronically once the recertification or revised CMN has been transmitted out of sequence Region D DMERC EDI Manual November 2001 Electronic Reports Page 25 Error EDIT Edit Explanation Code DESCRIPTION 3047 3052 RCT REV INIT DATE INVALID CANNOT REC REV DISC CMN CLSD NO REV The recertification or revised CMN transmitted electronically has an initial date that is not the same as the initial date on the initial CMN currently on file for the same procedure code For example CIGNA Medicare already has an initial CMN for a hospital bed set up with an initial date of 06 01 01 sent in by either Company A or Company B A recertification or revised CMN for 09 01 01 is transmitted by Company B and the initial date is 06 11 01 This would cause a 3047 CMN reject error code since CIGNA Medicare has on file an initial date of 06 01 01 Resolution The initial date on file with CIGNA Medicare will be returned on the CMN Reject Listing Verify the date submitted with the initial date on the CMN Reject Listing and if necessary correct the CMN and retransmit the claim and CMN If after contacting the beneficiary physician and or other supplier it still cannot be resolved
188. d for DMERC 10179 PAT DEMO DMG The segment providing the patient s demographic INFO information for this claim when other than the subscriber is SEGMENT missing This information is required when the patient is MISSING other than the insured This information is not used for DMERC 10180 PAT DOB DMGO1 The qualifier indicating the format used to report the QUAL INVALID patient s when other than the subscriber date of birth is invalid for this claim Valid Value D8 Date expressed in CCYYMMDD format This information is not used for DMERC 10181 PAT DOB DMG02 The date entered for the patient s date of birth when the INVALID patient is other than the subscriber is invalid for this claim When entered this information must be entered in a valid CCYYMMDD format This information is not used for DMERC 10182 PAT DOB DMG02 The date entered for the patient s date of birth when the FUTURE DATE patient is other than the subscriber is invalid for this claim When entered this information must not be greater than today s date This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 34 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10183 PAT SEX DMG03 The qualifier used to identify the patient s sex when other CODE INVALID than subscriber is invalid for this claim Valid Values F Female M Male U Unknown
189. d for DMERC 10214 INIT DTPO3 The initial treatment date entered is invalid for this claim TREATMENT When entered this information must be entered in a valid DT INVALID CCYYMMDD format FMT This information is not used for DMERC 10215 INIT DTPO3 The initial treatment date entered is invalid for this claim TREATMENT When entered this information must not be greater than DT FUTURE DT today s date This information is not used for DMERC 10216 REFERRAL DT DTP The segment providing the referral date for this claim SEG EXC MAX exceeds maximum use If this information is reported only 1 USE occurrence per claim may be used This information is not used for DMERC 10217 NOT USED 10218 REFERRAL DT DTP02 The qualifier indicating the format used to report the referral FMT Q INVALID date for this claim is invalid Valid Value D8 Date expressed in format CCYYMMDD This information is not used for DMERC 10219 REFERRAL DT DTPO3 The referral date entered is invalid for this claim When INVALID FMT entered this information must be entered in a valid CCYYMMDD format This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 41 Edit Edit Description Element Edit Explanation Number Segment ID 10220 REFERRAL DT DTPO3 The referral date entered is invalid for this claim When FUTURE DT entered this information must not be greater than
190. d in CCYYMMDD format www cignamedicare com edi Revised April 2003 Page 88 Chapter Seven Edit Number Edit Description Element Segment ID Edit Explanation 10493 OTH INS BIRTH DT INVALID DMG02 The date entered for the other payer s patient s date of birth is invalid for this line When entered this information must be entered in a valid CCYYMMDD format This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare This information is used for Medigap secondary to Medicare claims and should not be submitted unless there is an approved Medigap policy held by this subscriber 10494 OTH INS BIRTH DT FUTURE DT DMG02 The date entered for the other payer s patient s date of birth is invalid for this claim When entered this information must not be greater than today s date This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare This information is used for Medigap secondary to Medicare claims and should not be submitted unless there is an approved Medigap policy held by this subscriber 10495 OTH INS GENDER INVALID DMG03 The qualifier used to identify the other payer s patient s sex is invalid for this subscriber This information is used
191. d signature authorization form for HCFA 1500 Claim Form block 12 on file 10199 RELATED CLM11 2 The second related cause indicator is invalid for this claim If CAUSE 2 more than one related cause is indicated the second CODE INVALID occurrence of this indicator must be a valid value Valid Values AA Auto accident AB Abuse AP Another party responsible EM Employment OA Other accident www cignamedicare com edi Revised April 2003 Page 38 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10200 RELATED CLM11 3 The third related cause indicator is invalid If more than two CAUSE 3 related causes are indicated the third occurrence of this CODE INVALID indicator must be a valid value Valid Values AA Auto Accident AB Abuse AP Another Party Responsible EM Employment OA Other Accident 10201 AUTO ACC CLM11 4 If you have indicated an auto accident as the cause for this STATE claim you must submit a valid state abbreviation for the MISSING state where the accident occurred 10202 AUTO ACC CLM11 5 If you have indicated an auto accident as the cause for this COUNTRY claim and the accident occurred outside of the United INVALID States you must submit a country code 10203 SPEC PROG CLM12 The code indicating the special program under which the IND INVALID services rendered to the patient were performed is invalid for this claim Valid Values
192. d unless there is an approved Medigap policy held by this subscriber 20163 DEMO PROJECT ID REF02 You have indicated this is a demonstration project INVALID claim and you did not submit the demonstration project identifier code Valid Value 00803 Region C 20164 OTH PAYER SPV NM103 The other payer s supervising provider s last name was PRV LAST NAME entered in an invalid format Verify the first position of INV the other payer s supervising provider s last name is not a space and only contains alpha characters This information is not used for DMERC 20165 SPV PRV LAST NM103 The supervising provider s last name was entered in an NAME INVALID invalid format Verify the first position of the supervising provider s last name is not a space and only contains alpha characters This information is not used for DMERC 20166 CLAIM CONTROL REF02 If you receive this edit please contact the DMERC EDI NUMBER INVALID Department 20167 LINE ITEM CHANGE SV102 The amount entered for this line item charge was 0 and AMOUNT INVALID the code submitted requires a charge be entered 20168 ORDERING NM103 The ordering provider s last name was entered in an PROVIDER LAST invalid format Verify the first position of the ordering NAME INVALID provider s last name is not a space and only contains alpha characters www cignamedicare com edi Revised April 2003 Page 28 Chapter Eight Edit Number EDIT DESCRIPTION
193. d unless another payer adjudicated this claim prior to being submitted to Medicare 11036 ADJ UNITS CAS04 The amount entered as the line adjusted unit claim level is EXCEEDS MAX invalid If reported do not exceed the maximum number of DECIMAL positions to the right of the decimal point PLACES This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 11037 ADJ AMOUNT CAS06 The value entered as the line adjustment amount is invalid EXCEEDS If reported this amount cannot exceed 18 positions MAXIMUM This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 181 Edit Edit Description Element Edit Explanation Number Segment ID 11038 ADJ AMOUNT CAS06 The value entered as the line adjustment amount is invalid CANNOT HAVE If reported this value cannot exceed two positions to the gt 2 DEC right of the decimal point PLACES This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 11039 ADJUSTED CAS07 The value entered as the line adjustment adjusted units UNITS claim level amount is invalid If report
194. d verify that the information shown matches the Connection Requirements on page 3 of this chapter Leave the Script and Capture fields blank or on None Click Port Settings and select your Modem Connection Click OK to save your settings or click Dial to connect to the Stratus Network pc ANYWHERE 32 1 Click Start and then point to Programs Click on pe ANYWHERE 32 When the subfolder opens click on pe ANYWHERE to open the program Click on the Call Online Service button on the toolbar Double click Add Online Service Item to bring up the Call an Online Service Wizard When prompted for a name enter Stratus Network for the Online Service Phone Number enter 860 602 0000 Select VT100 for the terminal emulation Click Finish to save your work Double click on the Stratus Network icon to dial the telephone number Region D DMERC EDI Manual Revised June 2002 Stratus Network User Guide Page 5 Connect and Logon 1 Open your communications software package 2 Select the Stratus Network connection 3 Click Dial N amp stratus Phone number 8 1 860 6020000 Modify Your location New Location x Dialing Properties Calling card None Direct Dial 4 The following screen will appear while your modem is trying to connect amp stratus 7 8 1860 6020000 Courier V Everything External Status Dialing m www cignamedicare com edi Revised
195. data and is not all zeros or all nines and is either five or nine digits in length This information should only be reported if the patient is not the same as the subscriber 40011 RELEASE OF CLMO9 The release of information indicator entered for this claim is INFO INDICATOR not a valid value INVALID Valid Values M The provider has limited or restricted ability to release data related to a claim N No provider is not allowed to release data Y Yes provider has a signed statement permitting release of medical billing data related to a claim 40012 AMOUNT PAID BY AMT02 The amount entered as the patient paid amount was not BENE NOT NUMERIC entered in a numeric format Region D DMERC EDI Manual Revised April 2003 Edit EDIT Element Edit Explanation Number DESCRIPTION ID 40013 NOT USED 40014 ORDERING PROV NM1 The loop containing the ordering provider information is INFO MISSING missing This loop must be present for each service line of a DMERC claim 40021 CAPPED RENTAL SV101 2 The procedure code indicated on this line is a capped rental K MODIFIER item This code requires one of the following modifiers be MISSING appended to the code KH KI or KJ 40022 PROCEDURE V101 2 The procedure code indicated on this line is invalid Verify the CODE MODIFIER first position is not a space INVALID 40023 NUMBER OF SV104 The units of service entered for this line is invalid for the SER
196. der Identifier This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 150 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10821 CANNOT SEND N2 The segment providing additional supervising provider s gt 1 ADDTL SPV name information for this line exceeds maximum use When PROV NAME this information is reported only 1 occurrence per SEG transaction may be used This information is not used for DMERC 10822 CANNOT SEND REF The segment containing additional supervising provider gt 5 SPV PROV identification information exceeds maximum use When this 2ND ID information is reported only 5 occurrences per line may be SEGMENTS used This information is not used for DMERC 10823 SPV PROV REF01 The qualifier for the supervising provider secondary 2ND ID identification number information for this transaction is QUALIFIER invalid INVALID Valid Values OB State license number 1B Blue Shield provider number 1C Medicare provider number 1D Medicaid provider number 1G Provider UPIN number 1H CHAMPUS identification number B3 Preferred Provider Organization number El Employer s Identification Number G2 Provider commercial number LU Location number N5 Provider plan network identification number SY Social Security Number this may not be used for Medicare X5 State industrial Accident provider number This information is no
197. dicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare This information is used for Medigap secondary to Medicare claims and should not be submitted unless there is an approved Medigap policy held by this subscriber 10505 OTH INS FIRST NAME MISSING NM104 The first name of the other payer s insured is missing for this claim If you have specified the other payer s insured type to be a person this element must contain the first name of that person If the other payer s insured was identified as a non person entity this element is not used This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare This information is used for Medigap secondary to Medicare claims and should not be submitted unless there is an approved Medigap policy held by this subscriber Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 93 Edit Edit Description Element Edit Explanation Number Segment ID 10506 ID CODE NM108 The qualifier identifying the other subscriber identification QUALIFIER number for this claim is invalid INVALID Valid Values MI Member identification number ZZ Mutually defined This information is used for Medicare Secondary Payer claims and should not be submitted unles
198. dit Description Element Edit Explanation Number Segment ID 10190 TOTAL CLAIM CLMO1 The value entered to indicate the total claim charge is CHARGE invalid The amount reported must be greater than zero AMOUNT NOT gt 0 10191 PLACE OF CLMO5 1 An invalid place of service has been submitted for this claim SERVICE CODE INVALID Valid Values 11 Office 12 Home 21 Inpatient Hospital 22 Outpatient Hospital 23 Emergency Room Hospital 24 Ambulatory Surgical Center 25 Birthing Center 26 Military Treatment Facility 31 Skilled Nursing Facility 32 Nursing Facility 33 Custodial Care Facility 34 Hospice 41 Ambulance Land 42 Ambulance Air or Water 51 Inpatient Psychiatric Facility 52 Psychiatric Facility Partial Hospitalization 53 Community Mental Health Center 54 Intermediate Care Facility Mentally Retarded 55 Residential Substance Abuse Treatment Facility 56 Psychiatric Residential Treatment Center 50 Federally Qualified Health Center 60 Mass Immunization Center 61 Comprehensive Inpatient Rehabilitation Facility 62 Comprehensive Outpatient Rehabilitation Facility 65 End Stage Renal Disease Treatment Facility 71 State or Local Public Health Clinic 72 Rural Health Clinic 81 Independent Laboratory 99 Other Unlisted Facility www cignamedicare com edi Revised April 2003 Page 36 Chapter Seven Edit Edit Description El
199. djudicated this claim prior to being submitted to Medicare This information is used for Medigap secondary to Medicare claims and should not be submitted unless there is an approved Medigap policy held by this subscriber 20109 PRODUCT SERVICE ID QUALIFIER INVALID V101 1 The qualifier indicating the type of procedure code being submitted used for this line is invalid Valid Values HC HCPCS Codes N4 NDC Region D DMERC EDI Manual Revised April 2003 Front End Edits Medicare Page 19 Edit Number EDIT DESCRIPTION ElementID Edit Explanation 20110 PROCEDURE CODE SV101 2 The HCPCS or NDC code indicated on this claim line is INVALID not a valid code 20111 PROCEDURE SV101 3 The first modifier appended to the HCPCS code for this MODIFIER1 INVALID line is invalid Verify correct modifier usage in the DMERC Region D Supplier Manual 20112 PROCEDURE SV101 3 The modifier and HCPCS code combination reported MODIFIER1 INVALID for this line item is invalid Verify the correct modifier usage in the DMERC Region D Supplier Manual 20113 PROCEDURE SV101 4 The second modifier appended to the HCPCS code for MODIFIER2 INVALID this line is invalid Verify correct modifier usage in the DMERC Region D Supplier Manual 20114 PROCEDURE SV101 4 The second modifier and HCPCS code combination MODIFIER2 INVALID reported for this line item is invalid Verify the correct modifier us
200. e it is helpful to log the date of your claim transmission so that you do not miss downloading a receipt listing CIGNA Medicare stores copies of your files for 30 days If you need a file to be put back into your Stratus Network mailbox please contact the EDI Department Region D DMERC EDI Manual Revised June 2002 Stratus Network User Guide Page 19 Locating Downloaded Files When downloading from the Stratus Network using the Z modem protocol users sometimes find it difficult to locate their files because the Z modem protocol does not allow the user to choose a destination folder or directory when downloading Here is an easy way to locate those files using tools in Windows 95 98 or NT 4 0 This process may not work on computers using other operating systems 1 rn ww FF WY ND Download the file from the Stratus Network Exit your communications program used to connect to the Stratus Network Click on Start and then point to Find Click Files or Folders In the Named box type 00000 five zeroes In the Look In box select My Computer Make sure there is a checkmark in the Include subfolders box If not click on the box to select Click Find Now S Find All Files File Edit View Options Help Name amp Location Date Modified Advanced Named Joooag Look in My Computer Browse IV Include subfolders Stop New Search Once you click on Find Now the computer wil
201. e is missing for this CONTACT transaction A contact name for the billing provider must be NAME submitted with this transaction MISSING 10075 BILL PROV PERO3 The qualifier identifying the type of contact information being CONTACT provided for the billing provider is invalid for this transaction TYPE QUAL 1 INVALID Valid Values EM Electronic mail FX Facsimile TE Telephone 10076 BILL PROV PERO5 The qualifier identifying the second type of contact CONTACT information being provided for the billing provider is invalid TYPE QUAL 2 for this transaction INVALID Valid Values EM Electronic mail EX Telephone extension FX Facsimile TE Telephone 10077 BILL PROV PERO7 The qualifier identifying the third type of contact information CONTACT being provided for the billing provider is invalid for this TYPE QUAL 3 transaction INVALID Valid Values EM Electronic mail EX Telephone extension FX Facsimile TE Telephone 10078 PAYTO NAME NM1 The segment providing the pay to provider name information SEGMENT EXC for this transaction exceeds maximum use When this MAX USE information is reported only 1 occurrence per transaction may be used This information is not used for DMERC 10079 PAYTO NAME NM101 The qualifier identifying the pay to provider for this QUAL INVALID transaction is invalid Valid Value 87 Pay to provider This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003
202. e provider s specialization a segment of the population that a health care provider chooses to service a specific medical service a specialization in treating a specific disease or any other descriptive characteristic about the providers practice relating to the services rendered Trading Partner Any entity conducting electronic transactions with another entity Trading Partner Agreement An agreement related to the exchange of information in electronic transactions whether the agreement is distinct or part of a larger agreement between each party to the agreement Transaction Set The culmination of data that represents the information exchange between trading partners for a specified business process V Vendor An entity that provides hardware software and or ongoing technical support for providers suppliers Vendor Software Software written or developed by a third party entity vendor so that providers suppliers might submit claims to CIGNA Medicare If you already use vendor software to manage your practice contact the vendor to see if they offer a feature for submitting claims to Medicare Region D DMERC EDI Manual November 2001 Index Legend 1 1 Chapter 1 Page 1 Activity Log 5 26 ANSI 1 2 2 3 2 4 4 1 5 10 5 13 5 28 6 2 6 15 6 21 7 2 7 3 7 8 AT amp T Global Network Services 2 2 Beneficiary Eligibility 1 2 2 1 2 4 Benefits of Billing Electronically 1 1 1 2 Claim Control Number CCN 1 1 2 1 5 1
203. e rendering provider s last name are not any of the following MR MR DR DR JR or JR This information is not used for DMERC 20067 RENDERING NM104 The rendering provider s first name for this claim was PROVIDER FIRST entered in an invalid format Verify the first position of NAME INVALID the rendering provider s first name does not contain a space and the name only contains alpha characters This information is not used for DMERC 20068 RENDERING NM105 The rendering provider s middle name was entered in PROVIDER MIDDLE an invalid format for this claim Verify only alpha NAME INVALID characters are present This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 10 Chapter Eight Edit Number EDIT DESCRIPTION ElementID Edit Explanation 20069 RENDERING PROV PRV03 The rendering provider s taxonomy code indicated for SPECIALTY CODE this claim is invalid Verify the taxonomy code INVALID submitted against the taxonomy code list published by Washington Publishing Company To obtain a copy of this list visit their Web site at www wpc edi com This information is not used for DMERC 20070 RENDERING PROV REFO1 The qualifier for the rendering provider s secondary ID QUALIFIER identification number information for this claim is INVALID invalid Valid Value 1C Medicare provider number This information is not used for DMERC 20071 RENDERING PROV REF02 The p
204. e segment containing the responses to the questions on RESPONSES the CMN is missing This is a required segment for all lines MISSING containing a CMN 40078 TOTAL CLAIM CLM02 The total claim charges for this claim was not submitted CHARGE Please make sure you have entered your total claim charges AMOUNT and that it is equal to the total of all submitted line charges MISSING 40079 NUMBE OF SV104 The number of services for this line was not submitted SERVICES MISSING 40080 PATIENT HEIGHT MEA03 The subscriber s height was not included for this CMN CMN MISSING forms 2 03 and 10 02 require the height to be reported 40081 CMN LENGTH OF CR303 The CMN for this line did not have a length of need NEED MISSING submitted For all DMERC CMN s except form 8 02 a length of need must be reported 40082 OXYGEN CR502 The oxygen certification from 484 2 was submitted without a LENGTH OF length of need reported All oxygen certification forms require NEED MISSING a length of need 40083 BILLING PROV PRV The loop containing the billing provider information is missing INFO MISSING Please make sure your supplier information is submitted for each transaction 40085 SVC DATES NOT DTP The National Drug Code NDC submitted on this line for the WITHIN NDC date of service provided is invalid The NDC is not effective RNG for this date 40086 NDC CODE LINO3 The National Drug Code NDC submitted is invalid Verify INVALID the NDC was entered correctly
205. e submitter identification number reported is the number you were assigned by the EDI Department and not the National Supplier Clearinghouse or the Provider Enrollment Department 20005 PROVIDER PRV03 The billing provider s taxonomy code indicated for this SPECIALTY CODE transaction is invalid Verify the taxonomy code INVALID submitted against the taxonomy code list published by Washington Publishing Company To obtain a copy of this list visit their Web site at www wpc edi com 20006 BILLING PROVIDER N402 The state abbreviation indicated in this transaction for STATE INVALID the billing provider state is not a valid two character state abbreviation code 20007 BILLING PROVIDER N403 The zip code indicated in this transaction for the billing ZIP CODE INVALID provider s address was reported in an invalid format Verify the zip code contains only numeric data and is not all zeros or all nines and is either five or nine digits in length 20008 BILLING PROVIDER N404 The country code indicated in this transaction for the COUNTRY CODE billing provider s address is not a valid country code INVALID Region D DMERC EDI Manual Revised April 2003 Front End Edits Medicare Page 3 Edit Number EDIT DESCRIPTION ElementID Edit Explanation 20009 BILLING PROVIDER REFO1 The qualifier for the billing provider s secondary MEDICARE ID identification number Supplier number information for MISSING
206. ed In order to maintain the highest level of security the User ID and password you were assigned are for the use of your company only Please do not share your User ID or password with others CIGNA Medicare s EDI Department or the Customer Support Center will verify your User ID and Submitter ID when you call for support However once you change the initial password CIGNA Medicare is not able to verify your password Please keep this information in mind when calling the EDI Department or the Customer Support Center 10 Once your password is verified you will receive this message MBOO1A logged in at 2001 04 03 15 36 44 last login 2080 01 01 00 00 00 You have successfully logged on to CIGNA s gateway system This message is an example of a system message that can be displayed to a dial in user This file is easily updated in the operator interface Many companies use this system file to alert users to upgrades and new services that clients can sign up for or to further promote the system This screen however is optional You can eliminate this screen altogether and place the user directly into the menu system Press lt RETURN gt to continue gt _ 11 Press Enter to continue 12 The Main menu will appear CIGNA Gateway Service Tying in Customer s From Multiple Systems Ls 2 3 4 Please Enter Choice 1_ Mailbox Access Facility Download Activity Log Log off the System NEWS as of 01 19 01
207. ed Implementation Guide IG edits to ensure electronic files meet the HIPAA standard The IG edits and descriptions start on page 5 of this chapter The Medicare edits and descriptions are contained in Chapter 8 and the DMERC specific edits and descriptions are contained in Chapter 9 The IG edits check your electronic claims for format validation and are not specific to Medicare data requirements The IG edits can occur on any data element within the transaction even if it is not information used by Medicare Because the same transaction can accommodate multiple payers i e Medigap Medicaid and complementary crossover payers it is critical that all data within a transaction meet the standards set forth by the Implementation Guide The Medicare specific edits are designed to make sure that valid Medicare data is being transmitted in order to properly adjudicate the electronic claims These edits will only perform data validation to ensure we have the data required to process a Medicare claim The DMERC specific edits will validate data requirements specific to DMERC such as DMERC HCPCS NDC codes proper dates places of service and CMN data requirements Since our system processes both DMERC and Part B Medicare claims a separate level for editing DMERC requirements has been developed To allow you to quickly identify the level in which the error occurred the edits are numbered as follows 10XXX Implementation Guide edits 20XXX Medicare s
208. ed This information is not used for DMERC 10855 CANNOT SEND N2 The segment providing additional referring provider name gt 1 ADDTL REF information for this line exceeds maximum use When this PROV NAME information is reported only 1 occurrence per transaction SEG may be used This information is not used for DMERC 10856 CANNOT SEND REF The segment containing additional referring provider gt 5 REF PROV Identification information exceeds maximum use When this 2ND INFO SEG information is reported only 5 occurrences per line may be used This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 156 Chapter Seven Edit Number Edit Description Element Segment ID Edit Explanation 10857 REF PROV ID QUALIFIER INVALID REFO1 The qualifier for the referring provider secondary identification number information for this line is invalid Valid Values OB State license number 1B Blue Shield provider number 1C Medicare provider number 1D Medicaid provider number 1G Provider UPIN number 1H CHAMPUS identification number El Employer s identification number G2 Provider commercial number LU Location number N5 Provider plan network identification number SY Social Security Number X5 State industrial accident provider number This information is not used for DMERC 10858 REFERRING PROV UPIN MISSING REF02 The refer
209. ed this amount cannot EXCEEDS exceed 15 positions MAXIMUM This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 11040 ADJ UNITS CAS07 The value entered as the line adjustment adjusted units EXCEEDS MAX claim level is invalid If reported do not exceed the DECIMAL maximum number of positions to the right of the decimal PLACES point This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 11041 ADJ AMOUNT CAS09 The value entered as the line adjustment amount is invalid EXCEEDS If reported this amount cannot exceed 18 positions MAXIMUM This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 11042 ADJ AMOUNT CAS09 The value entered as the line adjustment amount is invalid CANNOT HAVE If reported this amount cannot exceed two positions to the gt 2 DEC right of the decimal point PLACES This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 11043 ADJUSTED CAS10 The value entered as the line adjustment adjusted units UNITS claim level amount is invalid If reported this amount cannot EXCEE
210. ed by stretcher 05 Patient was unconscious or in shock 06 Patient was transported in an emergency situation 07 Patient had to be physically restrained 08 Patient had visible hemorrhaging 09 Ambulance service was medically necessary 60 Transportation was to the nearest facility This information is not used for DMERC 10374 AMBO CERT CRC06 The qualifier indicating the patient s fourth condition is COND REAS 4 invalid for this ambulance claim INVALID Valid Values 01 Patient was admitted to a hospital 02 Patient was bed confined before the ambulance service 03 Patient was bed confined after the ambulance service 04 Patient was moved by stretcher 05 Patient was unconscious or in shock 06 Patient was transported in an emergency situation 07 Patient had to be physically restrained 08 Patient had visible hemorrhaging 09 Ambulance service was medically necessary 60 Transportation was to the nearest facility This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 64 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10375 AMBO CERT CRCO07 The qualifier indicating the patient s fifth condition is invalid COND REAS 5 for this ambulance claim INVALID Valid Values 01 Patient was admitted to a hospital 02 Patient was bed confined before the ambulance service 03 Patient was bed
211. edi com This information is not used for DMERC 11137 REFERRING PRV03 The referring provider s taxonomy code indicated for this line PROV is invalid Verify the taxonomy code submitted against the SPECIALITY taxonomy code list published by Washington Publishing CODE INVALID Company To obtain a copy of this list visit their Web site at www wpc edi com This information is not used for DMERC 11138 N2 SEGMENT N2 The segment providing additional name information for the NOT ALLOWED payer of this transaction is invalid IN X12 VERSION This edit indicates an invalid format and should be resolved by contacting your software vendor www cignamedicare com edi Revised April 2003 Page 194 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 11139 N2 SEGMENT N2 The segment providing additional name information for the NOT ALLOWED responsible party for this claim is invalid IN X12 VERSION This edit indicates an invalid format and should be resolved by contacting your software vendor 11140 N2 SEGMENT N2 The segment providing additional name information for the NOT ALLOWED credit debit card holder name for this claim is invalid IN X12 VERSION This edit indicates an invalid format and should be resolved by contacting your software vendor 11141 N2 SEGMENT N2 The segment providing additional name information for the NOT ALLOWED patient of this claim is invalid IN X12 VERSIO
212. edicare Introduction Front end edits are broken down into three categories or levels It is important to understand the differences between these levels to determine error resolution In addition to Medicare specific and DMERC specific edits CMS has required us to add Implementation Guide IG edits to ensure electronic files meet the HIPAA standard The IG edits and descriptions are contained in Chapter 7 The Medicare edits are included in this chapter and the DMERC specific edits and descriptions are contained in Chapter 9 To allow you to quickly identify the level in which the error occurred the edits are numbered as follows 10XXX Implementation Guide edits 20XXX Medicare specific edits 40XXX DMERC specific edits The Medicare edits are designed to make sure that valid Medicare data is being transmitted in order to properly adjudicate the electronic claims These edits will only perform data validation to ensure we have the data required to process a Medicare claim Since this level of editing is validating against the Medicare data requirements we have listed all valid Medicare values under the valid value section of each edit In an effort to prevent future edits from occurring at the DMERC level we have bolded and italicized the valid DMERC values that may be used for that element For your convenience we have indicated data elements in this section that are not used for DMERC If you receive an edit on data that is not used
213. edicare com dmerd edge index htm CSI SOFTWARE CLAIM STATUS INQUIRY The Claim Status Inquiry software CSI allows you to quickly check the status of your daims after they have been received by our system and assigned a Claim Control Number CCN http www cignamedicare com edi Products_and_Services index html REMIT NOTICE A paper or electronic payment report which lists daims that have been paid and or denied IVR INTERACTIVE VOICE RESPONSE The IVR is a toll free automated phone service that provides many different options to suppliers such as daim status Medicare benefidary eligibility information allowables and much more It is available for supplier usage as long as our mainframe is up and running and is available beyond the Customer Service hours of 8 00am to 6 00pm Central Standard Time Also there is no limit to the number of daims you can check in the IVR FREQUENTLY ASKED QUESTIONS CIGNA Medicare contracts with the Centers for Medicare amp Medicaid Services CMS to process Medicare claims and answer calls from providers and beneficiaries Due to a 163 increase in our call volume from 2002 callers are frequently receiving a busy signal on the current toll free line Those who need to speak to a Customer Service Agent are having a hard time getting through As a result CIGNA Medicare and CMS have developed a plan to add an additional toll free number to help alleviate busy signals and allow those wi
214. eject an interchange transmission that is submitted with a submitter identification number that is not authorized for electronic claim submission Page 2 DMERC Region D Companion Document Trading Partner Agreement e CIGNA Medicare will reject an interchange transmission that is submitted with an invalid value in GSO3 Application Receivers Code based on the carrier definition e CIGNA Medicare will reject an interchange transmission that is not submitted with a valid carrier code Each individual Contractor determines this code e CIGNA Medicare will reject an interchange transmission submitted with more than 9 999 loops e CIGNA Medicare will reject an interchange transmission submitted with more than 9 999 segments per loop e CIGNA Medicare will only accept claims for one line of business per transaction Claims submitted for multiple lines of business within one ST SE Transaction Set may cause the transaction to be rejected e CIGNA Medicare will only process one transaction per functional group a submitter must only submit one ST SE Transaction Set within a GS GE Functional Group e CIGNA Medicare will reject an interchange transmission with more than 5 000 CLM segments claims submitted per transaction e You may send up to eight diagnosis codes per claim however the last four diagnosis codes will not be considered in processing e Only valid qualifiers for Medicare should be submitted on incomi
215. ement Edit Explanation Number Segment ID 10192 CLM TYPE CLM05 3 The code indicating the type of claim being submitted is CODE INVALID invalid for this claim Valid Values 1 Original 6 Corrected 7 Replacement 8 Void 10193 SUP SIGN ON CLMO06 The code indicating the supplier s signature is on file is FILE INVALID invalid for this claim Valid Values Y Yes N No 10194 PROV ASSIGN CLM07 The provider assignment indicator for this claim is invalid IND INVALID Valid Values A Assigned B Assignment accepted on clinical lab services only C Not assigned P Patient refuses to assign benefits 10195 PAT ASSIGN CLM08 The patient assignment of benefits indicator is invalid for this BENEFITS IND claim Use Y to indicate Insured authorizes benefits to be INVALID paid to the supplier An N response indicates benefits have not been assigned to the supplier Valid Values N No Y Yes 10196 RELEASE OF CLMO9 The code specifying the type of release of information the INFO CODE patient has issued is invalid for this claim INVALID Valid Values A Appropriate release of information on file at health care service provider or at utilization review organization Informed consent to release medical information for conditions or diagnoses regulated by federal statutes M The provider has limited or restricted ability to release data related to a claim N No provider is not allowed to release data O
216. en FUTURE DATE entered this information must not be greater than today s date www cignamedicare com edi Revised April 2003 Page 126 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10648 FROM TO DTPO3 The date of service entered is invalid for this line When DATE INVALID entered this information must be entered in a CCYYMMDD CYYMMDD format 10649 FROM TO DTPO3 The date of service entered is invalid for this line When DATE FUTURE entered this information must not be greater than today s DATE date 10650 CERT DTP The segment providing the certification revision date for this REVISION DT line is missing This information must be provided if a MISSING revised or recertification CMN is being sent 10651 CERT DTP The segment providing the certification revision date for this REVISION DT line exceeds maximum use When this information is EXC MAX USE reported only 1 occurrence per line may be used 10652 NOT USED 10653 DTE TIME PER DTP02 The qualifier indicating the format used to report the FORMAT certification revision date for this line is invalid QUALIFIER INVALID Valid Value D8 Date expressed in format CCYYMMDD 10654 REVISION DTPO3 The certification revision date entered is invalid for this line DATE INVALID When entered this information must be entered in a valid CCYYMMDD format 10655 REVISION DTPO3 The certification rev
217. en test facility for this line item is invalid If a Medicare provider number was reported it must be a valid supplier number assigned by the National Supplier Clearinghouse Region D DMERC EDI Manual Revised April 2003 Front End Edits Medicare Page 23 Edit Number EDIT DESCRIPTION ElementID Edit Explanation 20138 SUPER PROV ID NM108 The qualifier identifying the supervising provider s CODE QUALIFIER identification number for this claim is invalid INVALID Valid Values 24 Employer s identification number 34 Social Security Number not used for Medicare XX Health Care Financing Administration National Provider Identifier This information is not used for DMERC 20139 ORDERING N402 The state abbreviation indicated on this line item for PROVIDER STATE the ordering provider state is not a valid two character CODE INVALID state abbreviation code 20140 ORDERING N403 The zip code indicated on this line item for the ordering PROVIDER ZIP provider address was reported in an invalid format CODE INVALID Verify the zip code contains only numeric data and is not all zeros or all nines and is either five or nine digits in length 20141 ORDERING N404 The country code indicated on this line item for the PROVIDER ordering provider is not a valid country code COUNTRY CODE INVALID 20142 ORDER PROV REFO1 The qualifier for the ordering provider s secondary SECOND REF ID identification number
218. ent ID Edit Explanation 20106 OTHER SUBSCRIBER ZIP CODE INVALID N403 The zip code indicated on this claim for the other insured s address was reported in an invalid format Verify the zip code contains only numeric data and is not all zeros or all nines and is either five or nine digits in length This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare This information is used for Medigap secondary to Medicare claims and should not be submitted unless there is an approved Medigap policy held by this subscriber 20107 OTHER SUBSCRIBER COUNTRY CODE INVALID N404 The country code indicated on this claim for the other insured s address is not a valid country code This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare This information is used for Medigap secondary to Medicare claims and should not be submitted unless there is an approved Medigap policy held by this subscriber 20108 OTHER PAYOR ID CODE QUALIFIER INVALID NM108 The qualifier identifying the other payer s identification number for this claim is invalid Valid Value PI Payor identification This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer a
219. ent providing additional service facility location or gt 1 ADDTL SVC oxygen test facility name information for this line exceeds FACILITY maximum use When this information is reported only 1 NAME occurrence per transaction may be used 10807 CANNOT SEND N3 The segment providing the service facility location or oxygen gt 1 SVC FAC test facility address for this line exceeds maximum use ADDRESS When this information is reported only 1 occurrence per transaction may be used www cignamedicare com edi Revised April 2003 Page 148 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10808 SVC FACILITY N4 The segment providing city state and zip code information C S Z for the service facility location or oxygen test facility for this SEGMENT line is missing When reporting address information the city MISSING state and zip code information must be included 10809 SVC FACILITY N401 The service facility location or oxygen test facility city is CITY MISSING missing for this line When reporting address information the city state and zip code information must be included 10810 SVC FACILITY N402 The service facility location or oxygen test facility state STATE abbreviation is missing for this claim When reporting MISSING address information the city state and zip code information must be included 10811 SVC FACILITY N403 The service facility locat
220. entifying the receiver for this transaction is NAME QUAL invalid INVALID Valid Value 40 Receiver 10045 RECEIVER NM102 The qualifier identifying the receiver type is invalid for this ENTITY TYPE transaction QUAL INVALID Valid Value 2 Non person entity 10046 RECEIVER NM103 The last name or company name is missing for this LAST ORG transaction If you have specified the receiver type to be a NAME person this element must contain the last name of that MISSING person If the receiver was identified as a non person entity this element must contain the company name 10047 RECEIVER ID NM108 The qualifier identifying the receiver Identification number for NUMBER this transaction is invalid QUAL INVALID Valid Value 46 Electronic Transmission Identification Number ETIN 10048 RECEIVER N2 The segment providing additional name information for the ADD NAME receiver for this transaction exceeds maximum use When SEGMENT EXC this information is reported only 1 occurrence per MAX USE transaction may be used This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 13 Edit Edit Description Element Edit Explanation Number Segment ID 10049 TRANS TYPE REFO1 The qualifier identifying the transmission type or claim OR CLAIM source is invalid for this transaction SOURCE QUAL INVALID Valid Values PR 87 If you receive this error please contac
221. epresenting the claim level adjusted amount EXCEEDS exceeds 18 positions MAXIMUM This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare www cignamedicare com edi Revised April 2003 Page 168 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10942 ADJ AMOUNT CAS15 The value representing the claim level adjusted amount CANNOT HAVE exceeds two positions to the right of the decimal point gt 2 DEC PLACES This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10943 ADJUSTED CAS16 The value representing the claim level adjusted units of UNITS service exceeds 15 positions EXCEEDS MAXIMUM This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10944 ADJ UNITS CAS16 The value representing the claim level adjusted units of EXCEEDS MAX service exceeds the maximum number of positions to the DECIMAL right of the decimal point PLACES This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10945 ADJ AMOUNT CAS18 The value
222. er CODE INVALID for this claim is invalid This information is used when a payer is submitting this claim to another payer and should not be submitted by the supplier Valid Value 82 Rendering provider This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 104 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10554 ENTITY TYPE NM102 The qualifier identifying the rendering provider type is invalid QUALIFIER for this claim INVALID This information is used when a payer is submitting this claim to another payer and should not be submitted by the supplier Valid Values 1 Person 2 Non person entity This information is not used for DMERC 10555 REND PROV NM103 The last name or company name is missing for this claim If LAST NAME you have specified the other payer rendering provider type MISSING to be a person this element must contain the last name of that person If the other payer rendering provider was identified as a non person entity this element must contain the company name This information is used when a payer is submitting this claim to another payer and should not be submitted by the supplier This information is not used for DMERC 10556 OTH PAY REF The segment containing additional other payer rendering REND PROV provider identification information is missing from this claim SEC EXC MAX USE This information is
223. er FY Claim office number NF National Association of Insurance Commissioners NAIC code TJ Federal taxpayer s identification number 9F Referral number G1 Prior authorization number T4 Signal code 10530 OTH PAYER REF02 The other payer s secondary identification number is SEC ID missing INVALID This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10531 OTH PAY PRI REF The segment containing the other payer prior authorization AUTH EXC or referral number information exceeds maximum use MAX USE When this information is reported only 2 occurrences per claim may be used This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10532 OTH PAY SBR NM1 The loop containing other subscriber information for the SEG MISSING other payer is missing or exceeds maximum use If this OR EXC MAX information is reported it can be reported no more than one USE time per claim This information is used for Medigap secondary to Medicare claims and should not be submitted unless there is an approved Medigap policy held by this subscriber 10533 OTH PAYER REF02 The other payer s referral number or prior authorization PRIOR AUTH number is missing for this claim INVALID This information is used for Medicare
224. er Seven Edit Edit Description Element Edit Explanation Number Segment ID 10027 X12 TRANS REF The segment identifying the X12 transmission type code for TYPE CODE this transaction is missing This information is required on all SEGMENT DMERC transactions MISSING 10028 X12 TRANS REFO1 The qualifier for the submitter identification number TYPE QUAL information for this transaction is invalid INVALID Valid Value 87 Functional Category 10029 X12 TRANS REF02 The code specifying the transmission type is invalid for this TYPE CODE transaction X12 requires one of the following values to INVALID identify the transaction being submitted Valid Values 004010X098D Used only in piloting this transaction set 004010X098 Used for all production claims 10030 SUBMITTER NM1 The segment providing name information for the submitter of NAME this transaction is missing This information is required on all SEGMENT DMERC transactions MISSING 10031 SUBMITTER NM101 The qualifier identifying the submitter for this transaction is NAME QUAL invalid INVALID Valid Value 41 Submitter 10032 SUBMITTER NM102 The qualifier identifying the submitter type is invalid for this ENTITY TYPE transaction QUAL INVALID Valid Values 1 Person 2 Non person entity 10033 SUBMITTER NM103 The last name or company name is missing for this LAST ORG transaction If you have specified the submitter type to be a NAME person this element must con
225. er and should not be submitted by the supplier This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 108 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10570 OTH PAY SER REF The segment containing additional other payer service FAC ID facility identification information is missing from this claim MISSING This information is not used for DMERC 10571 REF ID REFO1 The qualifier for the other payer service facility secondary QUALIFIER identification number information for this claim is invalid INVALID This information is used when a payer is submitting this claim to another payer and should not be submitted by the supplier Valid Values 1A Blue Cross provider number 1B Blue Shield provider number 1C Medicare provider number 1D Medicaid provider number G2 Provider commercial number LU Location number N5 Provider plan network identification number This information is not used for DMERC 10572 OTH PAY SER REF02 The other payer service facility secondary identification FAC ID number is missing for this claim INVALID This information is used when a payer is submitting this claim to another payer and should not be submitted by the supplier This information is not used for DMERC 10573 OTH PAY NM1 The segment providing the other payer supervising provider SUPER PROV name information for this claim exceeds maxim
226. erson 2 Non person entity This information is not used for DMERC 10439 ID CODE NM108 The qualifier identifying the purchased service provider QUALIFIER identification number for this claim is invalid INVALID Valid Values 24 Employers identification number 34 Social Security Number XX Health Care Financing Administration National Provider Identifier This information is not used for DMERC 10440 PURSH SER REF The segment containing additional purchased service PROV SEC ID provider identification information exceeds maximum use EXC MAX USE When this information is reported only 5 occurrences per claim may be used This information is not used for DMERC 10441 REF ID REFO1 The qualifier for the purchased service provider secondary QUALIFIER identification number information for this claim is invalid INVALID Valid Values OB State license number 1B Blue Shield provider number 1C Medicare provider number 1D Medicaid provider number 1G Provider UPIN number 1H CHAMPUS identification number El Employer s Identification Number G2 Provider commercial number LU Location number N5 Provider plan network identification number SY Social Security Number X5 State industrial accident provider number This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 78 Chapter Seven Edit Edit Description Element Edit Explanation N
227. es 11 Office 12 Home 21 Inpatient hospital 22 Outpatient hospital 23 Emergency room hospital 24 Ambulatory surgical center 25 Birthing center 26 Military treatment facility 31 Skilled nursing facility 32 Nursing facility 33 Custodial care facility 34 Hospice 41 Ambulance land 42 Ambulance air or water 50 Federally qualified health center 51 Inpatient psychiatric facility 52 Psychiatric facility partial hospitalization 53 Community mental health center 54 Intermediate care facility mentally retarded 55 Residential substance abuse treatment facility 56 Psychiatric residential treatment center 60 Mass immunization center 61 Comprehensive inpatient rehabilitation facility 62 Comprehensive outpatient rehabilitation facility 65 End stage renal disease treatment facility 71 State or local public health clinic 72 Rural health clinic 81 Independent laboratory 99 Other unlisted facility 10588 COMP DIAG CODE POINT MISSING SV107 The diagnosis code pointer information is missing for this line This information is required for all line items www cignamedicare com edi Revised April 2003 Page 112 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10589 DIAG CODE SV107 1 The first diagnosis code pointer for this line item is invalid POINTER Use this code to point back to the primary di
228. es are available on the Washington Publishing Company Web site at www wpc edi com AT amp T Global Services Network The network formerly IBM Global Services Network utilized by users of AT amp T Passport for Windows communications software in order to utilize Claim Status Inquiry CSD AT amp T Passport for Windows Communications software used to access Claim Status Inquiry CSI B Beneficiary Eligibility A feature that enables participating providers suppliers to electronically access information regarding the eligibility data of beneficiaries Billing Provider The entity submitting electronic claims This will be the provider of medical services who is requesting adjudication of the claim Billing Service An entity that provides claims services to providers suppliers It compiles medical information to build and transmit claims They will collect claim information from a provider supplier electronically or on paper and will bill the appropriate insurance payer Note You are responsible for verifying that claims are being transmitted electronically and for the accuracy of claims that a billing service or clearinghouse sends to CIGNA Medicare on your behalf C Claim Control Number CCN A tracking number assigned by CIGNA Medicare to claims that were accepted into its claims processing system Certificates of Medical Necessity CMN Reject Report A report that lists all CMNs that were rejected after the claim was accepted into
229. escription Element Edit Explanation Number Segment ID 10257 LAST X RAY DTPO3 The last X ray date entered is invalid for this claim When DT FUTURE DT entered this information must not be greater than today s date This information is not used for DMERC 10258 EST DOB SEG DTP The segment providing the estimated date of birth for this EXC MAX USE claim exceeds maximum use If this information is reported only 1 occurrence per claim may be used This information is not used for DMERC 10259 NOT USED 10260 EST DOB FMT DTP02 The qualifier indicating the format used to report the date of Q INVALID birth for this claim is invalid Valid Value D8 Date expressed in format CCYYMMDD This information is not used for DMERC 10261 EST DOB DTPO3 The estimated date of birth entered is invalid for this claim INVALID FMT When entered this information must be entered in a CCYYMMDD format This information is not used for DMERC 10262 EST DOB DTPO3 The estimated date of birth entered is invalid for this claim FUTURE DT When entered this information must not be greater than today s date This information is not used for DMERC 10263 HEAR VIS RX DTP The segment providing the hearing and vision prescription DT SEG EXC date for this claim exceeds maximum use If this information MAX USE is reported only 1 occurrence per claim may be used This information is not used for DMERC 10264 NOT USED 10265 HEAR VIS RX DTP02 The qualifier indicating the forma
230. escription Element Edit Explanation Number Segment ID 10383 VIS COND CRCO07 The qualifier indicating the fifth condition causing the need REAS 5 for replacement lenses or frames is invalid for this claim INVALID Valid Values L1 General standard of 20 degree or 5 diopter sphere Or cylinder change met L2 Replacement due to loss or theft L3 Replacement due to breakage or damage L4 Replacement due to patient preference L5 Replacement due to medical reason This information is not used for DMERC 10384 HMBND TEST CRC The segment containing information when an independent SEG EXC MAX laboratory renders an EKG tracing or obtains a specimen USE from a homebound or institutionalized patient exceeds maximum use If this information is reported only 1 occurrence per claim may be used This information is not used for DMERC 10385 NOT USED 10386 HMBND COND CRC02 The homebound condition response code is invalid for this CODE INVALID claim Valid Values Y Yes N No This information is not used for DMERC 10387 HMBND COND CRCO3 The qualifier indicating the patient is independent within their REAS Q home is invalid for this claim INVALID Valid Value IH Independent at home This information is not used for DMERC 10388 DIAG CODE HI The segment providing the diagnosis information for this SEGMENT EXC claim exceeds maximum use When this information is MAX USE reported only 1 occurrence per claim may be used 10389 DIAG CODE 1 HI01
231. f the decimal point gt 2 DEC This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10967 COB TOT CLM AMTO2 The value representing the primary payer s total claim B4 TAXES before taxes amount exceeds 18 positions EXCEEDS MAXIMUM This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10968 COB TOT CLM AMTO2 The value representing the primary payer s total claim B4 TAXES before taxes amount exceeds two positions to the right of CANNOT HAVE the decimal point gt 2 DEC This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10969 OUTPT REIMB_ MOA01 The value representing the Medicare outpatient RATE reimbursement rate exceeds 18 positions EXCEEDS MAXIMUM This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 172 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10970 OUTPT REIMB MOA01 The value representing the Medicare outpatient RATE CANNOT reimbursement rate exceeds two positions to the right of the HAVE gt 2 DEC decimal point This information is not used for DMERC
232. fication number 23 Client number IG Insurance policy number SY Social Security Number This information is not used for DMERC 10127 SUBSCRIBER REF02 The subscriber secondary identification number is missing ID 2 MISSING for this subscriber This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 26 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10129 PAYER NAME NM1 The segment providing name information for the payer of SEGMENT this transaction is missing This information is required on all MISSING DMERC transactions 10130 PAYER NAME NM101 The qualifier identifying the payer for this transaction is QUAL INVALID invalid Valid Value PR Payer 10131 PAYER ENTITY NM102 The qualifier identifying the payer type is invalid for this TYPE QUAL transaction INVALID Valid Value 2 Non person entity 10132 PAYER NAME NM103 The company name is missing for this transaction If the MISSING payer was identified as a non person entity this element must contain the company name 10133 PAYER ID NBR NM108 The qualifier identifying the payer identification number for QUAL INVALID this transaction is invalid Valid Values PI Payer identification XV Health Care Financing Administration National Plan Identifier 10134 PAYER ADD N2 The segment providing additional payer name information NAME for this claim exceeds
233. firmation will not tell you if your claims have been accepted into our processing system it will confirm that a file was transmitted successfully to the Stratus Network www cignamedicare com edi Page 2 Chapter Six 997 Functional Acknowledgment report 997 report The 997 Functional Acknowledgment report is a report generated to recognize received ANSI X12N files This report will be generated for each transaction received by CIGNA Medicare that contains enough data in a valid format to identify the user In most cases this report will tell you that the file received was a valid ANSI file In which case the 997 in element AK901 will contain a code of A for accepted and you will not need to do anything with the 997 However if an R appears in the 997 the file sent must be corrected and retransmitted This is a new report to all DMERC electronic billers and provides an intermediary status of the sender s file between Stratus and the front end edits see Chapter 7 of this manual for more information on edits This report does not replace the Electronic Report Package The Electronic Report Package will still be generated to acknowledge data errors The 997 report is validating high level formatting where the Electronic Report Package validates data and detailed formatting requirements The 997 report will be available within 2 hours of transmission of the file The 997 will be returned to the user s Stratus Network mailbox ident
234. first position of the address information does not contain a space 20027 SUBSCRIBER N302 The subscriber s additional address information listed ADDRESS82 INVALID on this claim was entered in an invalid format Verify the first position of the additional address information does not contain a space 20028 SUBSCRIBER CITY N401 The city indicated on this claim for the subscriber s city NAME INVALD is invalid Verify the first position of the name of the city does not contain a space 20029 SUBSCRIBER N402 The state abbreviation indicated on this claim for the STATE CODE subscriber state is not a valid two character state INVALID abbreviation code 20030 SUBSCRIBER ZIP N403 The zip code indicated on this claim for the subscriber s CODE INVALID address was reported in an invalid format Verify the zip code contains only numeric data and is not all zeros or all nines and is either five or nine digits in length 20031 SUBSCRIBER N404 The country code indicated on this claim for the COUNTRY CODE subscriber s address is not a valid country code INVALID 20032 SUBSCRIBER BIRTH DMG02 The subscriber s date of birth indicated on this claim is DATE INVALID invalid Verify the date is not greater than today s date and that the century was entered as either 18 19 or 20 20033 SUBSCRIBER DMGO03 The subscriber s sex code indicated on this claim is GENDER CODE invalid INVALID Valid Values M Male F Female 20034 PAYOR ID CODE NM108 The qualifier ide
235. format This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10527 ADJUD PYMT DTP03 The date claim paid entered is invalid for this claim When DT FUTURE DT entered this information must not be greater than today s date This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10528 OTH PAYER REF The segment containing additional other payer identification SEC ID EXC information exceeds maximum use When this information is MAX USE reported only 2 occurrences per claim may be used This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 99 Edit Edit Description Element Edit Explanation Number Segment ID 10529 REF ID REFO1 The qualifier entered for the other payer s secondary QUALIFIER identification information for this claim is invalid INVALID This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare Valid Values 2U Payer identification number F8 Original reference numb
236. format and should be resolved by contacting your software vendor 10008 IN CREATE ISA09 The creation date entered is invalid for this interchange This information must not be greater than today s date This edit indicates an invalid format and should be resolved by contacting your software vendor Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 7 Edit Edit Description Element Edit Explanation Number Segment ID 10009 IN CREATE ISA10 The creation time entered is invalid for this interchange The TIME INVALID information must be entered in a HHMM format based on a 24 hour clock This edit indicates an invalid format and should be resolved by contacting your software vendor 10010 IN CONTROL ISA11 The code identifying the interchange control standards is QUAL INVALID invalid for this interchange This element requires the following value to be used Valid Value U U S EDI Community of ASC X12 TDCC and UCS This edit indicates an invalid format and should be resolved by contacting your software vendor 10011 IN VERSION ISA12 The version number for this interchange is invalid This NUMBER element requires the following value to be used INVALID Valid Value 00401 ASC X12 Standard Version This edit indicates an invalid format and should be resolved by contacting your software vendor 10012 IN ACK ISA14 The qualifier indicating a request for an interchange REQUEST acknowledgement i
237. ftware vendor 10885 PT WEIGHT PAT08 The value entered to indicate the patient weight is invalid EXCEEDS When reporting this value it cannot exceed 10 positions MAXIMUM 10886 PT WEIGHT PAT08 The value entered to indicate the patient weight is invalid EXCEEDS MAX When this information is reported do not exceed the DECIMAL maximum number of positions to the right of the decimal PLACES point 10887 PT WEIGHT PATO08 The value representing the patient s weight exceeds two EXCEEDS positions to the right of the decimal point MAXIMUM 10888 PT WEIGHT PAT08 The value entered to indicate the patient weight is invalid CANNOT BE When reporting this value it cannot exceed 10 positions gt 10 POSITIONS 10889 TOT CLM CHG CLM02 The value representing the total claim charge amount EXCEEDS exceeds 18 positions MAXIMUM www cignamedicare com edi Revised April 2003 Page 162 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10890 TOT CLM CHG CLM02 The value representing the total claim charge amount CANNOT HAVE exceeds two positions to the right of the decimal point gt 2 DEC PLACES 10891 CONTRACT CN102 The value representing the contract information amount AMT EXCEEDS exceeds 18 positions MAXIMUM This information is not used for DMERC 10892 CONTRACT CN102 The value representing the contract Information amount AMT CANNOT exceeds two positions to the rig
238. g the ERNs on a daily or weekly basis Once the ERN file has been downloaded from your Stratus mailbox an ERN reader is required to view and print out in a readable format ERN reader software may be purchased from a software vendor If you would like to program your own ERN reader software you will need to download the ANSI X12N 4010 835 Implementation Guide This may be downloaded free of charge from www wpc edi com Receiving ERNs The following are the necessary steps to begin receiving ERNs 1 Complete the DMERC EDI Customer Profile form and select ERNs as an additional feature This form is located in the Appendix of this manual It is also available through the EDI Web site section located at www cignamedicare com edi 2 Return completed form to CIGNA Medicare 3 Upon receipt CIGNA Medicare will process your request to begin receiving your remittance advices electronically Note Please allow 10 21 business days for processing Note If you have elected to sign up to receive ERNs and are currently using the Electronic Funds Transfer EFT option all paper remittance notices will be discontinued in 30 days www cignamedicare com edi Page 4 Chapter Two Beneficiary Eligibility Beneficiary Eligibility is an option available to participating suppliers only This function allows participating suppliers to send CIGNA Medicare a file containing beneficiary information and CIGNA Medicare will send a file back including inform
239. haracter state INVALID abbreviation code 20054 COUNTRY CODE CLM11 5 The auto accident country code is invalid INVALID 20055 ACCIDENT DATE DTP This claim indicates there was an automobile accident MISSING abuse another responsible party or some other accident involved and the date of that occurrence was not reported 20056 PATIENT AMOUNT AMT02 The amount entered on this claim as the amount the PAID INVALID patient paid is invalid Verify the amount that was entered as what the patient paid does not exceed the total amount of the claim 20057 DIAGNOSIS 1 HI01 2 The first diagnosis code indicated on this claim is INVALID invalid Verify the diagnosis code submitted on this claim is a valid ICD 9 diagnosis code 20058 DIAGNOSIS 2 HI02 2 The second diagnosis code indicated on this claim is INVALID invalid Verify the diagnosis code submitted on this claim is a valid ICD 9 diagnosis code 20059 DIAGNOSIS 3 HI03 2 The third diagnosis code indicated on this claim is INVALID invalid Verify the diagnosis code submitted on this claim is a valid ICD 9 diagnosis code 20060 DIAGNOSIS 4 HI04 2 The fourth diagnosis code indicated on this claim is INVALID invalid Verify the diagnosis code submitted on this claim is a valid ICD 9 diagnosis code 20061 DIAGNOSIS 5 HI05 2 The fifth diagnosis code indicated on this claim is INVALID invalid Verify the diagnosis code submitted on this claim is a valid ICD 9 diagnosis code This information is not used
240. hen a payer is submitting this claim to another payer and should not be submitted by the supplier 10546 ENTITY ID CODE INVALID NM1 The segment providing the referring provider name information for this claim is invalid If used the second occurrence of the other payer referring provider name segment at the claim level must contain information on the primary care provider This information is used when a payer is submitting this claim to another payer and should not be submitted by the supplier 10547 ENTITY TYPE QUALIFIER INVALID NM102 The qualifier identifying the referring provider type is invalid for this claim This information is used when a payer is submitting this claim to another payer and should not be submitted by the supplier Valid Values 1 Person 2 Non person entity 10548 REF PROV LAST NAME MISSING NM103 The last name or company name is missing for this claim If you have specified the other payer s referring physician type to be a person this element must contain the last name of that person If the other payer s referring physician was identified as a non person entity this element must contain the company name This information is used when a payer is submitting this claim to another payer and should not be submitted by the supplier Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 103 Edit Edit Descr
241. her payers for this subscriber is invalid Valid Values P Primary S Secondary T Tertiary 10098 SUBSCRIBER SBR02 The qualifier indicating the subscriber s relation to the REL TO insured for this Payer Medicare is invalid INSURED INVALID Valid Value 18 Self Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 21 Edit Edit Description Element Edit Explanation Number Segment ID 10099 MSP REASON SBRO5 The qualifier identifying the type of Medicare secondary CODE INVALID coverage for this subscriber is invalid Valid Values 12 Medicare secondary working aged beneficiary or spouse with employer group health plan 13 Medicare secondary end stage renal disease beneficiary in the 12 month coordination period with an employer s group health plan 14 Medicare secondary no fault insurance including auto is primary 15 Medicare secondary worker s compensation 16 Medicare secondary public health service or other federal agency 41 Medicare secondary black lung 42 Medicare secondary Veteran s Administration 43 Medicare secondary disabled beneficiary under age 65 with large group health plan 47 Medicare secondary other liability insurance is primary This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare www cignamed
242. his claim is INVALID FOR invalid X12 VERS Valid Values AA Auto Accident AP Another Party Responsible EM Employment OA Other Accident 11165 aces CLM11 3 The third related causes code entered for this claim is INVALID FOR valid X12 VERS Valid Values AA Auto Accident AP Another Party Responsible EM Employment OA Other Accident 11166 OER EQ SV5 You have included the durable medical equipment service RR NU OR UE segment and the procedure code for which payment is being RENT PRCH i requested does not contain a rental or purchase modifier RR NU or UE This information is not used for DMERC 11167 SRL ETUE CR201 The treatment service number included with this claim in USED IN X12 mwaa VER This edit indicates an invalid format and should be resolved by contacting your software vendor This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 198 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 11168 SPINL MANIP CR202 The spinal manipulation treatment count included with this TREAT CNT claim is invalid NOT USD IN X12 VER This edit indicates an invalid format and should be resolved by contacting your software vendor This information is not used for DMERC 11169 SUBLUX LVL CR203 The subluxation level code included with this claim is invalid CODE 1 NOT USED IN X12 This edit indicates an invalid form
243. his claim prior to being submitted to Medicare 10954 COB AMT02 The value representing the primary payer allowed amount ALLOWED AMT exceeds two positions to the right of the decimal point CANNOT HAVE gt 2 DEC This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10955 COB PT RESP AMT02 The value representing the primary payer s patient AMT EXCEEDS responsibility amount exceeds 18 positions MAXIMUM This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare www cignamedicare com edi Revised April 2003 Page 170 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10956 COB PT RESP AMT02 The value representing the primary payer s patient AMT CANNOT responsibility amount exceeds 2 positions to the right of the HAVE gt 2 DEC decimal point This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10957 COB AMT02 The value representing the primary payer s covered amount COVERED exceeds 18 positions AMT EXCEEDS MAXIMUM This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer
244. ht of the decimal point HAVE gt 2 DEC PLACES This information is not used for DMERC 10893 TERMS DISC CN105 The value representing the contract terms discount percent PERCENT amount exceeds six positions EXCEEDS MAXIMUM This information is not used for DMERC 10894 TERMS DISC CN105 The value representing the contract terms discount percent CANNOT amount exceeds two positions to the right of the decimal HAVE gt 2 DEC point PLACES This information is not used for DMERC 10897 PT PD AMT AMT02 The value representing the patient paid amount for this EXCEEDS claim exceeds 18 positions MAXIMUM 10898 PT PD AMT AMT02 The value representing the patient paid amount for this CANNOT HAVE claim exceeds two positions to the right of the decimal point gt 2 DEC PLACES 10899 TOT PURCH AMT02 The value representing the total purchased service amount SVC AMT for this claim exceeds 18 positions EXCEEDS MAXIMUM Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 163 Edit Edit Description Element Edit Explanation Number Segment ID 10900 TOT PURCH AMT02 The value representing the patient paid amount for this SVC AMT claim exceeds two positions to the right of the decimal point CANNOT HAVE gt 2 DEC 10901 PT WEIGHT CR102 The value representing the patient weight exceeds 10 EXCEEDS positions MAXIMUM This information is not used for DMERC 10902 PT WEIGHT CR102 The val
245. i Revised April 2003 Page 154 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10845 CANNOT SEND NM1 The segment providing the referring provider name gt 2 REF PROV information for this claim exceeds maximum use When this NAME information is reported only 2 occurrences per line may be SEGMENTS used This information is not used for DMERC 10846 DOES NOT NM1 The segment providing the referring provider name EQUAL DN information for this line is invalid If used the first occurrence of the name segment at the line level must contain information on the referring provider This information is not used for DMERC 10847 DOES NOT NM1 The segment providing the referring provider name EQUAL P3 information for this line is invalid If used the second occurrence of the referring provider name segment at the line level must contain information on the primary care provider This information is not used for DMERC 10848 REF PROV ID NM101 The qualifier identifying the referring provider for this line is CODE INVALID invalid Valid Values DN Referring provider P3 Primary care provider This information is not used for DMERC 10849 REF PROV NM102 The qualifier identifying the referring provider type is invalid NAME for this line QUALIFIER INVALID Valid Value 1 Person This information is not used for DMERC 10850 REF PROV NM103 The last name is missing for this line If you have specif
246. icare com edi Revised April 2003 Page 22 Chapter Seven Edit Number Edit Description Element Segment ID Edit Explanation 10100 MSP COVERAGE TYPE CODE INVALID SBRO9 The qualifier identifying the type of Medicare coverage for this subscriber is invalid Valid Values 09 Self pay 10 Central certification 1725 11 Other non federal programs 12 Preferred Provider Organization PPO 13 Point of Service POS 14 Exclusive Provider Organization EPO 15 Indemnity insurance 16 Health Maintenance Organization HMO Medicare Risk AM Automobile medical BL BlueCross Blue Shield CH Champus Cl Commercial insurance company DS Disability HM Health Maintenance Organization LI Liability LM Liability medical MB Medicare Part B MC Medicaid OF Other federal program VA Veteran Administration plan WC Workers compensation health claim ZZ Mutually defined unknown This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10101 SUBSCRIBER DT OF DEATH FMT QUAL INVALID PAT05 The qualifier indicating the format used to report the patient s date of death for this claim is invalid Valid Value D8 Date expressed in format CCYYMMDD 10102 SUBSCRIBER DATE OF DEATH INVALID PATO6 The patient s date of death entered is inv
247. id Valid Value MI Member identification number This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare This information is used for Medigap secondary to Medicare claims and should not be submitted unless there is an approved Medigap policy held by this subscriber 20102 OTHER SUBSCRIBER ADDRESS1 INVALID N301 The other insured s address listed on this claim was entered in an invalid format Verify the first position of the address information does not contain a space This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare This information is used for Medigap secondary to Medicare claims and should not be submitted unless there is an approved Medigap policy held by this subscriber Region D DMERC EDI Manual Revised April 2003 Front End Edits Medicare Page 17 Edit Number EDIT DESCRIPTION Element ID Edit Explanation 20103 OTHER SUBSCRIBER ADDRESS2 INVALID N302 The other insured s additional address information listed on this claim was entered in an invalid format Verify the first position of the address information does not contain a space This information is used for Medicare Secondary Payer claims and should not be submitted u
248. id Values 24 Employer s Identification Number 34 Social Security Number XX National Provider number This information is not used for DMERC 10798 PUR SER REF The segment containing additional purchased service PROV SEC ID provider identification information exceeds maximum use EXC MAX USE When this information is reported only 5 occurrences per line may be used This information is not used for DMERC 10799 REF ID REFO1 The qualifier for the purchased service provider secondary QUALIFIER identification number information for this line is invalid INVALID Valid Values OB State license number 1B Blue Shield provider number www cignamedicare com edi Revised April 2003 Page 146 Chapter Seven Edit Edit Description Number Element Segment ID Edit Explanation 1C Medicare provider number 1D Medicaid provider number 1G Provider UPIN number 1H CHAMPUS identification number El Employer s Identification Number G2 Provider commercial number LU Location number N5 Provider plan network identification number SY Social Security Number U3 Unique supplier identification number X5 State industrial accident provider number This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 147 Edit Edit Description Element Edit Explanation Number Segment ID 10800 PUR SER
249. ider as TPO Third Party Organization participant T2 Cannot identify payer as TPO Third Party Organization participant T3 Cannot identify insured as TPO Third Party Organization participant T4 Payer name or identifier missing T5 Certification information missing T6 Claim does not contain enough information for re pricing This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 69 Edit Edit Description Element Edit Explanation Number Segment ID 10400 REPRICER HCP 14 The repricer s policy compliance code is invalid for this CMPL CODE claim INVALID Valid Values 1 Procedure followed compliance 2 Not followed call not made non compliance call not made 3 Not medically necessary non compliance non medically necessary 4 Not followed other non compliance other 5 Emergency admit to non network hospital This information is not used for DMERC 10401 REPRICER HCP15 The repricer s exception code is invalid for this claim EXCEPT CODE INVALID Valid Values 1 Non network professional provider in network hospital 2 Emergency Care 3 Services or specialist not in network 4 Out of service area 5 State mandates 6 Other This information is not used for DMERC 10402 HMHLTH CARE CR7 The segment reporting home health care plan information SEG EXE MAX exceeds maximum use If this information is reported only 1
250. ider for this claim is invalid This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare This information is used for Medigap secondary to Medicare claims and should not be submitted unless there is an approved Medigap policy held by this subscriber Valid Value IL Insured or subscriber www cignamedicare com edi Revised April 2003 Page 92 Chapter Seven Edit Edit Description Number Element Segment ID Edit Explanation 10503 ENTITY TYPE QUALIFIER INVALID NM102 The qualifier identifying the subscriber type is invalid for this claim This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare This information is used for Medigap secondary to Medicare claims and should not be submitted unless there is an approved Medigap policy held by this subscriber Valid Values 1 Person 2 Non person entity 10504 OTH INS LAST NAME MISSING NM103 The last name or company name is missing for this claim If you have specified the other payer s insured type to be a person this element must contain the last name of that person If the other payer s insured has been identified as a non person entity this element must contain the company name This information is used for Me
251. ied LAST NAME the referring provider type to be a person this element must MISSING contain the last name of that person This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 155 Edit Edit Description Element Edit Explanation Number Segment ID 10851 REF PROV NM104 The first name of the referring provider is missing for this FIRST NAME line If you have specified the referring provider type to be a MISSING person this element must contain the first name of that person If the referring provider was identified as a non person entity this element is not used This information is not used for DMERC 10852 REF PROV ID NM108 The qualifier identifying the referring provider identification CODE number for this line is invalid QUALIFIER INVALID Valid Values 24 Employers Identification Number 34 Social Security Number XX Health Care Financing Administration National Provider Identifier This information is not used for DMERC 10853 REF PROV PRVO1 The qualifier identifying the type of provider being reported CODE for this line is invalid MISSING INVA LID Valid Value RF Referring This information is not used for DMERC 10854 REF PROV PRV02 The qualifier identifying the type of identification number SPECIALITY being reported for the referring provider is invalid for this QUALIFIER line MISS INV Valid Value ZZ Mutually defin
252. ification number information for this claim is invalid INVALID Valid Values OB State license number 1B Blue Shield provider number 1C Medicare provider number 1D Medicaid provider number 1G Provider UPIN number 1H CHAMPUS identification number El Employer s Identification Number G2 Provider commercial number LU Location number N5 Provider plan network identification number SY Social Security Number X5 State Industrial Accident Provider Number This information is not used for DMERC 10435 REND PROV REF02 The rendering provider secondary identifier is missing for SEC ID this claim MISSING This information is not used for DMERC 10436 PURCH SER NM1 The segment providing the purchased service provider PROV NAME name information for this claim exceeds maximum use EXC MAX USE When this information is reported only 1 occurrence per claim may be used This information is not used for DMERC 10437 ENTITY ID NM101 The qualifier identifying the purchased service provider for CODE INVALID this claim is invalid Valid Value QB Purchase service provider This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 77 Edit Edit Description Element Edit Explanation Number Segment ID 10438 ENTITY TYPE NM102 The qualifier identifying the purchased service provider type QUALIFIER is invalid for this claim INVALID Valid Values 1 P
253. ified in the incoming 837 transaction This file may be downloaded by selecting RECEIVE_ACK from the Select Data Type option See Chapter 5 for downloading instructions Note During production the 997 reports will be available upon the following schedule j 3 997 report If submitted before available after 9 00 a m ET 9 30 a m ET 12 00 p m ET 12 30 p m ET 2 00 p m ET 2 30 p m ET 5 00 p m ET 6 00 p m ET 8 00 p m ET 6 00 a m ET This report will be generated in the ANSI X12 997 format and will require a reader program for interpretation If you do not have a 997 reader program please contact your software vendor CIGNA Medicare does not provide reader software The following pages contain examples of the 997 report for both an accepted and a rejected transaction They are broken down by element with descriptions provided for the key elements If you download a 997 and it indicates a rejected status correct the errors identified on the 997 and retransmit the transaction If you need help in determining what caused the transaction to reject contact your software vendor If you would like more information on the specific elements of the 997 you may download the ANSI X12N 837 version 4010 Implementation Guide free of charge at www wpc edi com Region D DMERC EDI Manual November 2001 Example Rejected 997 ISA 00 00 Z7 05655 ZZ M BOO1A 010730 1638 U 00401 000000001 0 T GS H C 05655 M BO01A 20010730 00001638 000000001
254. ight on DMERC CMN forms 2 03 and 10 02 Valid Value 01 Actual Pounds This information is not used for DMERC 11157 AS PATO7 The code used to indicate the measurement of the patient s WHEN weight is missing for this claim If the patient s weight is WEIGHT reported this is a required element PRESENT Valid Value 01 Actual Pounds This information is not used for DMERC 11158 Feel PATO8 The value entered as the patient s weight for this claim is MISSING invalid When reported this value must be numeric and greater than zero This information is not used for DMERC 11159 DTP ORDER DTP The segment providing the order date for this claim is DATE NOT invalid ALLOWED IN X12 VERSION This edit indicates an invalid format and should be resolved by contacting your software vendor Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 197 Edit Edit Description Element Edit Explanation Number Segment ID 11160 DTP REF DATE DTP oe Tr The segment providing the referral date for this claim is be eee invalid VERSION This edit indicates an invalid format and should be resolved by contacting your software vendor 11161 E DTP The segment providing the estimated date of birth for this NOT ALLOWED claim is invalid IN X12 VER This edit indicates an invalid format and should be resolved by contacting your software vendor 11164 E E CLM11 2 The second related causes code entered for t
255. ile File Name Example TM_MDTI gt MXXXX0O_2001 08 22 000002 7 The first part of the filename shows what type of transfer was attempted It will show TM_MDTI for test or TM_MDPI for production The final character of this block shows if the file was uploaded I Inbound or downloaded O Outbound In our example above the filename indicates it was a test file TM_MDTI and it was uploaded I The last block starts with the login ID This will be the MB number that sent or received this file In our example the login ID is MXXXXO The date the file was created This will be the original date this file was entered into your mailbox Outbound files are only available for seven days after this date under most circumstances In the above example the file was entered into your mailbox on August 22 2001 denoted by 2001 08 22 Sequence number Each file sent in a day will have a different sequence number assigned by the Stratus Network The sequence number for the above example is 000002 7 Region D DMERC EDI Manual Revised June 2002 Stratus Network User Guide Page 21 Opening Your Downloaded Files When opening the file if the Open With dialog box appears it means that your computer has not associated a program with the file name extension assigned by the Stratus Network Select either WordPad or Notepad from the list of programs Cick the program you wort to we fo open the Ae 10 100 161 22 the pagam you wart isnot in the ict ci
256. im is invalid Verify the claim adjustment reason code was entered as it appears on the explanation of benefits from the primary payer This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 20151 LINE ADJUSTMENT REASON CODE3 INVALID CAS08 The line level claim adjustment reason code indicated on this claim is invalid Verify the claim adjustment reason code was entered as it appears on the explanation of benefits from the primary payer This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 20152 LINE ADJUSTMENT REASON CODE4 INVALID CAS11 The line level claim adjustment reason code indicated on this claim is invalid Verify the claim adjustment reason code was entered as it appears on the explanation of benefits from the primary payer This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 20153 LINE ADJUSTMENT REASON CODE5 INVALID CAS14 The line level claim adjustment reason code indicated on this claim is invalid Verify the claim adjustment reason code was entered as it appears on the explanation of benefits from the primary payer This information is
257. im prior to being submitted to Medicare This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 158 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10865 OTHER PAYER REFO1 The qualifier for the other payer prior authorization or QUALIFIER referral identification number information for this line is INVALID invalid Valid Values 9F Referral number G1 Prior authorization number This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare This information is not used for DMERC 10866 CANNOT SEND SVD The segment providing the line adjudication information for gt 25 LINE this line exceeds maximum use When this information is ADJUD INFO reported only 25 occurrences per transaction may be used SEGMENTS This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10867 DOES NOT SVD01 The identification code for line adjudication information is EQUAL invalid for this line 2330B NM109 This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10868 PROD SVC ID SVD03 1 The qualifier indicating the line adjudication
258. ine may be used This information is not used for DMERC 11255 N2 SEGMENT N2 The segment providing additional name information for the NOT ALLOWED pay to provider of this transaction in invalid IN X12 VERSION This edit indicates an invalid format and should be resolved by contacting your software vendor www cignamedicare com edi Revised April 2003 Page 208 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 11256 N2 SEGMENT N2 The segment providing additional name information for the NOT ALLOWED subscriber for this claim is invalid IN X12 VERSION This edit indicates an invalid format and should be resolved by contacting your software vendor 11257 LENGTH SV503 The value representing the number of days being reported MEDICAL as the length of medical necessity exceeds 15 positions NECESS EXCEEDS This information is not used for DMERC MAXIMUM 11258 LENGTH MED SV503 The value representing the number of days being reported NECESSITY as the length of medical necessity exceeds the maximum INV DECIMAL number of positions to the right of the decimal point FORMAT This information is not used for DMERC 11259 NDC CODE LIN You have indicated this claim line to have a National Drug MISSING Code NDC associated with it however the segment used to provide the NDC is missing Region D DMERC EDI Manual Revised April 2003 Chapter Eight Front End Edits M
259. information for this line item is QUAL INVALID invalid Valid Value 1G Provider UPIN number 20143 ORDERING REF02 The secondary identification number indicated on this PROVIDER claim for the ordering provider for this line item is SECONDARY ID invalid The provider UPIN reported must be a valid INVALID UPIN Number 20144 REFERING PRV03 The referring provider s taxonomy code indicated for PROVIDER this line item is invalid Verify the taxonomy code SPECIALTY CODE submitted against the taxonomy code list published by INVALID Washington Publishing Company To obtain a copy of this list visit their Web site at www wpc edi com This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 24 Chapter Eight Edit Number EDIT DESCRIPTION Element ID Edit Explanation 20145 PRIOR AUTH ID CODE QUALIFIER INVALID NM108 The qualifier identifying the identification number other payer who issued the prior authorization or referral number is invalid Valid Value PI Payor identification This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 20146 PRODUCE SERVICE ID QUALIFIER INVALID SVD03 1 The qualifier indicating the other payer s type code for this line is invalid Valid Values HC HCPCS code N4 NDC code This information is
260. ing provider for this line is invalid IN X12 VERSION This edit indicates an invalid format and should be resolved by contacting your software vendor This information is not used for DMERC 11152 N2 SEGMENT N2 The segment providing additional name information for the NOT ALLOWED referring provider for this line is invalid IN X12 VERSION This edit indicates an invalid format and should be resolved by contacting your software vendor This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 196 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 11153 are PATO The code used to indicate the measurement of the patient s IN X12 weight is invalid for this claim This is used to report the VERSION subscriber s weight on DMERC CMN forms 2 03 and 10 02 Valid Value 01 Actual Pounds 11154 ESS PAT07 The code used to indicate the measurement of the patient s WHEN weight is missing for this claim If the subscriber s weight is WEIGHT reported this is a required element PRESENT Valid Value 01 Actual Pounds 11155 rate aa PAT08 The value entered to represent the subscriber s weight is MISSING invalid When entered this value must be a numeric value greater than 0 11156 eB PATO7 The code used to indicate the measurement of the patient s IN X12 weight is invalid for this claim This is used to report the VERSION patient s we
261. int This information is not used by DMERC www cignamedicare com edi Revised April 2003 Page 178 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 11017 FREQUENCY HSD04 The value entered as the frequency count of the health care CNT EXCEEDS services delivery is invalid If entered this amount cannot MAXIMUM exceed 6 positions This information is not used by DMERC 11018 FREQUENCY HSD04 The value entered as the frequency count of the health care CNT CANNOT services delivery is invalid If entered this amount cannot HAVE contain a decimal point DECIMAL This information is not used by DMERC 11019 ALLOW AMT HCP02 The value entered as the line pricing repricing information PRICING allowed amount is invalid If entered this amount cannot EXCEEDS exceed 18 positions MAXIMUM This information is not used by DMERC 11020 ALLOW AMT HCP02 The value entered as the line pricing repricing information PRICING allowed amount is invalid If reported this value cannot CANNOT HAVE exceed two positions to the right of the decimal point gt 2 DEC This information is not used by DMERC 11021 SAVINGS AMT HCP03 The value entered as the line pricing repricing savings PRICING amount information is invalid If reported this amount cannot EXCEEDS exceed 18 positions MAXIMUM This information is not used by DMERC 11022 SAVINGS AMT HCP03 The value entered as the
262. invalid Valid Value BF Diagnosis ICD 9 codes This information is not used for DMERC 10396 DIAG CODE 8 HI08 1 The qualifier identifying the type of diagnosis code being QUAL INVALID sent eighth with this claim is invalid Valid Value BF Diagnosis ICD 9 codes This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 68 Chapter Seven Edit Number Edit Description Element Segment ID Edit Explanation 10397 REPRICER METHOD CODE INVALID HCP01 The pricing methodology code used to indicate how this claim has been priced or repriced is invalid Valid Values 00 Zero pricing not covered under contract 01 Priced as billed at 100 02 Priced at the standard fee schedule 03 Priced at a contractual percentage 04 Bundled pricing 05 Peer review pricing 07 Flat rate pricing 08 Combination pricing 09 Maternity pricing 10 Other pricing 11 Lower of cost 12 Ratio of cost 13 Cost reimbursed 14 Adjustment Pricing This information is not used for DMERC 10398 REPRICER ALLOW AMT MISSING HCP02 The repriced allowed amount for this claim is missing This information is not used for DMERC 10399 REPRICER REASON CODE INVALID HCP13 The qualifier identifying the reason code for rejecting this service by the repricer is invalid for this claim Valid Values T1 Cannot identify prov
263. ion is not used for DMERC 10463 REF ID REFO1 The qualifier for the supervising provider secondary QUALIFIER identification number information for this claim is invalid INVALID Valid Values OB State license number 1B Blue Shield provider number 1C Medicare provider number 1D Medicaid provider number 1G Provider UPIN number 1H CHAMPUS identification number El Employer s Identification Number G2 Provider commercial number LU Location number N5 Provider plan network identification number SY Social Security Number X5 State industrial accident provider number This information is not used for DMERC 10464 SUPER PROV REF02 The supervising secondary identification number is missing SEC ID for this claim MISSING This information is not used for DMERC 10465 PAYOR RESP SBRO1 The qualifier indicating the responsibility of this payer other SEQ CODE payer in relation to Medicare for this subscriber is invalid INVALID This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare Valid Values P Primary S Secondary T Tertiary www cignamedicare com edi Revised April 2003 Page 82 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10466 IND REL CODE SBRO2 The qualifier indicating the patient s relation to the insured INVALID for this paye
264. ion or oxygen test facility zip code is ZIP MISSING missing for this line When reporting address information the city state and zip code information must be included 10812 CANNOT SEND REF The segment containing additional service facility location or gt 5 SVC FAC oxygen test facility identification information exceeds 2ND ID maximum use When this information is reported only 5 SEGMENTS occurrences per line may be used 10813 SVC FAC LOC REFO1 The qualifier for the service facility location or oxygen test 2ND ID facility secondary identification number information for this QUALIFIER line is invalid INVALID Valid Values OB State license number 1A Blue Cross provider number 1B Blue Shield provider number 1C Medicare provider number 1D Medicaid provider number 1G Provider UPIN number 1H CHAMPUS identification number G2 Provider commercial number LU Location number N5 Provider plan network identification number TJ Federal taxpayer s identification number X4 Clinical Laboratory Improvement Amendment CLIA number X5 State industrial accident provider number 10814 FACILITY REF02 The service facility location or oxygen test facility secondary PROV identification code is missing for this line NUMBER MISSING Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 149 Edit Edit Description Element Edit Explanation Number Segment ID
265. ious or in shock 06 Patient was transported in an emergency situation 07 Patient had to be physically restrained 08 Patient had visible hemorrhaging 09 Ambulance service was medically necessary 60 Transportation was to the nearest facility This information is not used for DMERC 10372 AMBO CERT CRC04 The code indicating the patient s secondary condition is COND REAS 2 invalid for this ambulance claim INVALID Valid Values 01 Patient was admitted to a hospital 02 Patient was bed confined before the ambulance service 03 Patient was bed confined after the ambulance service 04 Patient was moved by stretcher 05 Patient was unconscious or in shock 06 Patient was transported in an emergency situation 07 Patient had to be physically restrained 08 Patient had visible hemorrhaging 09 Ambulance service was medically necessary 60 Transportation was to the nearest facility This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 63 Edit Edit Description Element Edit Explanation Number Segment ID 10373 AMBO CERT CRC05 The code indicating the patient s third condition is invalid for COND REAS 3 this ambulance claim INVALID Valid Values 01 Patient was admitted to a hospital 02 Patient was bed confined before the ambulance service 03 Patient was bed confined after the ambulance service 04 Patient was mov
266. iption Element Edit Explanation Number Segment ID 10549 OTH PAY REF REF The segment containing additional other payer s referring PROV ID provider identification information is missing MISSING This information is used when a payer is submitting this claim to another payer and should not be submitted by the supplier 10550 REF ID REFO1 The qualifier for the other payer s referring provider QUALIFIER secondary identification number information for this claim is INVALID invalid This information is used when a payer is submitting this claim to another payer and should not be submitted by the supplier Valid Values 1B Blue Shield provider number 1C Medicare provider number 1D Medicaid provider number El Employer s Identification Number G2 Provider commercial number LU Location number N5 Provider plan network identification number 10551 OTH PAY REF REF02 The other payer referring provider secondary identification PROV ID number is missing for this claim MISSING This information is used when a payer is submitting this claim to another payer and should not be submitted by the supplier 10552 OTH PAY NM1 The segment providing the other payer rendering provider REND PRO name information for this claim exceeds maximum use EXC MAX USE When this information is reported only 1 occurrence per claim may be used This information is not used for DMERC 10553 ENTITY ID NM101 The qualifier identifying the other payer rendering provid
267. is information is not used for DMERC 10627 COND CODE INVALID CRC04 The code indicating the patient s secondary condition is invalid for this ambulance line Valid Values 01 Patient was admitted to a hospital 02 Patient was bed confined before the ambulance service 03 Patient was bed confined after the ambulance service 04 Patient was moved by stretcher 05 Patient was unconscious or in shock 06 Patient was transported in an emergency situation 07 Patient had to be physically restrained 08 Patient had visible hemorrhaging 09 Ambulance service was medically necessary 60 Transportation was to the nearest facility This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 122 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10628 COND CODE CRC05 The qualifier indicating the patient s third condition is invalid INVALID for this ambulance line Valid Values 01 Patient was admitted to a hospital 02 Patient was bed confined before the ambulance service 03 Patient was bed confined after the ambulance service 04 Patient was moved by stretcher 05 Patient was unconscious or in shock 06 Patient was transported in an emergency situation 07 Patient had to be physically restrained 08 Patient had visible hemorrhaging 09 Ambulance service was medically necessary 60 Transportation was t
268. is line item is invalid POINTER 3 INVALID Valid Values 1 2 3 4 20123 DIAGNOSIS CODE V107 4 The diagnosis code pointer for this line item is invalid POINTER 4 INVALID Valid Values 1 2 3 4 20124 SERVICE DATE DTP03 The date of service entered for this line item is invalid INVALID Verify the date of service is greater than 19811231 and if you are reporting a span date range that the to date is not a future date Region D DMERC EDI Manual Revised April 2003 Front End Edits Medicare Page 21 Edit Number EDIT DESCRIPTION Element ID Edit Explanation 20125 RENDERING PROV NM103 The rendering provider s last name was entered in an LNAME OR ORG invalid format Verify the first position of the rendering INVALID provider s last name is an alpha character and does not contain spaces Make sure the first three positions of the other insured s last name are not any of the following MR MR DR DR JR or JR This information is not used for DMERC 20126 RENDERING NM104 The rendering provider s first name for this claim line PROVIDER FIRST was entered in an invalid format Verify the first position NAME INVALID of the rendering provider s first name does not contain a space and the name only contains alpha characters This information is not used for DMERC 20127 RENDERING NM105 The rendering provider s middle name was entered in PROVIDER MIDDLE an invalid format for this line Verif
269. ision date entered is invalid for this line DATE FUTURE When entered this information must not be greater than DATE today s date 10656 REFERRAL DT DTP The segment providing the referral date for this line exceeds EXC MAX USE maximum use When this information is reported only 1 occurrence per line may be used This information is not used for DMERC 10657 NOT USED 10658 DTE TIME PER DTP02 The qualifier indicating the format used to report the referral FORMAT date for this line is invalid QUALIFIER INVALID Valid Value D8 Date expressed in format CCYYMMDD This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 127 Edit Edit Description Element Edit Explanation Number Segment ID 10659 REFFERAL DTPO3 The referral date entered is invalid for this line When DATE INVALID entered this information must be entered in a CCYYMMDD format This information is not used for DMERC 10660 REFFERAL DTPO3 The referral date entered is invalid for this line When DATE FUTURE entered this information must not be greater than today s DATE date This information is not used for DMERC 10661 BEG THERAPY DTP The segment providing the begin therapy date CMN initial DT EXC MAX date for this line exceeds maximum use When this USE information is reported only 1 occurrence per line may be used 10662 NOT USED 10663 DTE TIME PER DTP02 The qu
270. issing for S3E security end segment S4E security end segment missing for S4S security start segment S4S security start segment missing for S4E security end segment www cignamedicare com edi Page 26 Chapter Six Segment Element ae ae and Name Element Description Valid Values with Description Element AK906 Functional Group Syntax Code AK907 Functional Group Syntax Code AK908 Functional Group Syntax Code AK090 Functional Group Syntax Code Repeat AK905 if additional codes apply Repeat AK905 if additional codes apply Repeat AK905 if additional codes apply Repeat AK905 if additional codes apply Region D DMERC EDI Manual November 2001 Page 14 Chapter Six Electronic Report Package The most valuable advantage of billing electronically is the ability to track your claims once they are received by CIGNA Medicare Within 48 hours after you transmit your claims an Electronic Report Package is available for downloading This is a set of reports that provide specific information as it relates to each claim you transmitted Using these reports will allow you to quickly determine the total number of claims you transmitted the number of claims accepted into our system for processing and when applicable the reasons why claims were rejected This section identifies and describes each of the reports that are generated Although there are multiple reports you may not receive every one when you download your Elec
271. itted unless another payer adjudicated this claim prior to being submitted to Medicare 10871 CANNOT SEND DTP The segment providing the line adjudication date for this line gt 1 2430 DTP exceeds maximum use When this information is reported SEGMENT only 1 occurrence per line may be used This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10872 DATE TIME DTPO1 The qualifier for the line adjudication date for this line is QUALIFIER invalid INVALID Valid Value 573 Date claim paid This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10873 DTP FORMAT DTP02 The qualifier indicating the format used to report the line QUALIFIER adjudication date for this line is invalid INVALID Valid Value D8 Date expressed in format CCYYMMDD This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare www cignamedicare com edi Revised April 2003 Page 160 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10874 ADJ OR PMT DTPO3 The line adjudication or payment date entered is invalid for DATE INVALID this line When entered this infor
272. justments exceeds maximum use If this information is reported only 5 occurrences per claim may be used This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 85 Edit Edit Description Element Edit Explanation Number Segment ID 10470 CLM ADJ GRP CASO1 The qualifier specifying the claim adjustment group code for CODE INVALID the adjustments being reported is invalid for this claim This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare Valid Values CO Contractual obligation CR Correction or reversal OA Other adjustment PI Payer initiated adjustment PR Patient responsibility 10471 COB PAYER AMT The segment providing the amount the primary payer paid PD AMT EXC exceeds maximum use If this information is reported only 1 MAX USE occurrence per claim may be used This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10472 NOT USED 10473 COB APP AMT AMT The segment providing the amount the primary payer EXC MAX USE approved exceeds maximum use If this information is reported only
273. l a Select your protocol x modem 1k x modem y modem z modem or Kermit by entering the character that corresponds to your selection i e type Z for ZMODEM Your modem protocol selected in your communications software and the Stratus Network protocol default must match i e if your communications software is set to zmodem then your Stratus Network connection should be set to z modem as well Function Selected Put a file in your mailbox UPLOAD Enter PROTOCOL selection X for XMODEM Y for YMODEM 1 for 1K XMODEM K for KERMIT Z for ZMODEM or Q to QUIT 4 In your software click the Transfer pull down menu and select Send File For additional assistance in uploading files refer to your communications software user guide Region D DMERC EDI Manual Revised June 2002 Stratus Network User Guide Page 15 5 Your software will prompt you to select the file to send To find your file click on Browse Once you have selected the file click on Open and then Send The file will begin downloading to your computer Function Selected Put a file in your mailbox UPLOAD Enter PROTOCOL selection X for XMODEM Y for YMODEM 1 for 1K XMODEM K for KERMIT Z for ZMODEM or Q to QUIT Send File 1 21 x Receiving FILENAME wil Folder C WINNT cigna ml_dO2 gt FXF_7 gt 2_ Filename gt z Place your PC in Protocol set options 32 bit Zmodem z Send Close Cancel Press lt RETURN gt af
274. l start looking for files containing 00000 in the file name The search results will appear in the window at the bottom of the Find dialog box The results will include the file name the folder that contains the file the file size the file type and the date modified for each file found To view the entire path of a specific file expand the width of the In Folder column by positioning the pointer on the right border of the column heading When the pointer becomes a double headed arrow P drag the column border to the right until the entire path is displayed i e C Program Files ProComm Download The z modem protocol will always save a downloaded file to this location you can save time by writing down this path and keeping it for the next time you download Once the path of the Stratus Network file has been identified and you have written it down close out of the Find dialog box 10 Using any word processing program or text editor i e Word WordPerfect WordPad or Notepad open the file a On the File menu click Open b Inthe Files of Type field select All Files c Inthe File Name field type the complete path as written down in Step 9 i e C Program Files ProComm Download d Click Open www cignamedicare con vedi Revised June 2002 Page 20 Chapter Five e Highlight the file name that you would like to open and click Open Below is a description of the file name that the Stratus Network assigns to each f
275. l whom ordered supplies for the subscriber The Ordering Provider is the physician who provided the order to the subscriber or completed the DMERC CMN P Patient The individual for whom a health insurance claim is being submitted if different from the subscriber For Medicare claim purposes this will not apply because the patient beneficiary will always be the subscriber Payer The entity from which payment is being requested Payment Floor The minimum amount of time a claim must be held before payment can be released EMC claims must remain on the payment floor 13 days before payment is released Paper claims must remain on the payment floor for 26 days before payment is released Pay to Provider The entity receiving payment for the claims being sent in this transaction This provider information would only be used if the pay to provider is different from the billing provider This information is not used for DMERC claim processing because the billing provider represents the company whom provided the services for this claim Proprietary Software This software is written or developed in house for a company and tailored to the specific needs of that company Specifications for the HIPAA compliant ANSI X12N version 4010 implementation guides are available on the Washington Publishing Company Web Site at www wpc edi com Qualifier A code from an approved code list used to define the data contained in the element following the qualifier
276. laim is invalid INVALID This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare Valid Values 1W Member identification number 23 Client number IG Insurance policy number SY Social Security Number This information is not used for DMERC 10511 OTH SUB SEC REF02 The other insured s secondary identification number is ID MISSING missing for this claim This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare This information is not used for DMERC 10512 OTH PAYER NM1 The segment providing the other payer name information for NAME EXC this claim exceeds maximum use When this information is MAX USE reported only 1 occurrence per claim may be used This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare This information is used for Medigap secondary to Medicare claims and should not be submitted unless there is an approved Medigap policy held by this subscriber Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 95 Edit Edit Description Element Edit Explanation Number Segment ID 10513 ENTITY ID NM101 The qualifier identifyi
277. le party s first name was entered in an PARTY FIRST NAME invalid format Verify the first position of the responsible INVALID party s first name does not contain a space and the name only contains alpha characters 20041 RESPONSIBLE NM105 The responsible party s middle name was entered in an PARTY MIDDLE invalid format Verify only alpha characters are present NAME INVALID 20042 RESPONSIBLE N301 The responsible party s address listed on this claim PARTY ADDESS1 was entered in an invalid format Verify the first position INVALID of the address information does not contain a space 20043 RESPONSIBLE N302 The responsible party s additional address information PARTY ADDRESS2 listed on this claim was entered in an invalid format INVALID Verify the first position of the address information does not contain a space 20044 RESONSIBLE N401 The city indicated on this claim for the responsible PARTY CITY NAME party s city is invalid Verify the first position of the INVALID name of the city does not contain a space 20045 RESPONSIBLE N402 The state abbreviation indicated on this claim for the PARTY STATE responsible party state is not a valid two character state CODE INVALID abbreviation code Region D DMERC EDI Manual Revised April 2003 Front End Edits Medicare Page 7 Edit Number EDIT DESCRIPTION Element D Edit Explanation 20046 RESPONSIBLE N403 The zip code indicated on this claim for the responsi
278. lid Valid Value 1C Medicare provider number This information is not used for DMERC 20016 PAY TO PROVIDER REF02 The secondary identification number indicated in this SECONDARY ID INVALID transaction for the pay to provider is invalid Verify the number entered is a valid supplier number as assigned by the National Supplier Clearinghouse This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 4 Chapter Eight Edit Number EDIT DESCRIPTION ElementID Edit Explanation 20017 PAY TO PROVIDER REF02 The secondary identification number indicated in this SECONDARY ID transaction for the pay to provider is not currently INVALID authorized to bill electronically and or we do not have an EDI Enrollment form on file This information is not used for DMERC 20018 SUBSCRIBER SBR04 You have indicated there is a primary payer other than INSURED GROUP Medicare for this subscriber by entering a group or NAME MISSING policy number and leaving the group or plan name blank You must include a group or plan name when reporting this information 20019 CLAIM FILLING SBRO9 The qualifier used to identify the claim filing indicator for INDICATOR CODE this subscriber is invalid INVALID Valid Value MB Medicare Part B 20020 PATIENT WEIGHT PAT08 The amount entered for the patient weight for this INVALID subscriber is invalid 20021 SUBSCRIBER LAST NM103 The subscriber
279. ll free number 877 320 0390 Suppliers calling on the beneficiary toll free line will also be instructed to disconnect and call the appropriate number Can we opt out for a Customer Service Agent when using the IVR Unfortunately when accessing the toll free IVR number suppliers will not have the capability to transfer directly to an agent Will still be able to speak to a Customer Service Agent Yes however suppliers should first seek out information from the various resources listed on the Resource Sheet If you can not obtain information from one of these avenues at that time you may contact a Customer Service Agent don t like using the IVR Do you have any plans to make it more user friendly CIGNA Medicare is always looking for ways to improve our IVR Several changes have already been put in place to make our IVR more user friendly CIGNA Medicare is constantly monitoring and updating the features of the IVR as needed Your comments suggestions or questions about using the IVR may be directed to any of our Customer Service Agents How do obtain the most current DMERC Dialogue or any other CIGNA Medicare publication CIGNA Medicare s Web site has DMERC Dialogues from March 1997 to current as well as the Region D Supplier Manual If you would like to order publications from CIGNA Medicare s Office Services an order form can be accessed from the following link http www cignamedicare com dmerc resource himl
280. lue entered as the oxygen saturation test result INVALID question 1B on the oxygen certification form is not numeric 40030 CRC SEGMENT CRC The segment containing information on conditions as MISSING FOR indicated on the durable medical equipment CMN or oxygen CMN certification form is missing 40031 SERVICE FROM DTP03 The service from date is missing on this line DATE MISSING 40032 SERVICE FROM DTPO3 The date entered to indicate the service from date was DATE INVALID entered in an invalid format Verity the date is a valid date contains 19 or 20 as the century and was entered ina CCYYMMDD format 40033 SERVICE TO DTPO3 The service to date is missing on this line DATE MISSING 40034 SERVICE TO DTPO3 The date entered to indicate the service to date was entered DATE INVALID in an invalid format Verity the date is a valid date contains 19 or 20 as the century and was entered in a CCYYMMDD format 40035 SERVICE TO DTPO3 The to date is prior to the from date The to date must be DATE LESS THAN equal to or greater than the from date FROM DATE 40036 SERVICE FROM DTPO3 The procedure code submitted for this line does not allow for DATE DOES NOT spanned dates of service Verify the from and to dates for this EQUAL TO DATE line are equal 40037 SERVICE DATE DTPO3 The date entered to indicate the service from date is greater GREATER THAN RECEIPT DATE than the date this claim was received by CIGNA DMERC Region D DMERC EDI Manual
281. lue representing the primary payer paid amount PD AMT exceeds 18 positions EXCEEDS MAXIMUM This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10950 COB PAYER AMT02 The value representing the primary payer paid amount PD AMT exceeds two positions to the right of the decimal point CANNOT HAVE gt 2 DEC This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10951 COB AMT02 The value representing the primary payer approved amount APPROVED exceeds 18 positions AMT EXCEEDS MAXIMUM This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10952 COB AMT02 The value representing the primary payer approved amount APPROVED exceeds two positions to the right of the decimal point AMT CANNOT HAVE gt 2 DEC This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10953 COB AMT02 The value representing the primary payer allowed amount ALLOWED AMT exceeds 18 positions EXCEEDS MAXIMUM This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated t
282. lved by contacting your software vendor This information is not used for DMERC 11180 TREAT CR206 You have included the time period involved in this PERIOD chiropractic treatment series This information is invalid COUNT NOT USED IN X12 This edit indicates an invalid format and should be resolved ERS by contacting your software vendor This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 200 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 11181 MO NBR CR207 You have included the number of chiropractic treatments CHIRO TREAT rendered in the month This information is invalid NOT USED IN X12 VERS This edit indicates an invalid format and should be resolved by contacting your software vendor This information is not used for DMERC 11182 CHIRO COMPL CR209 You have included the value representing spinal CODE NOT manipulation complications for this line This information is USED IN X12 invalid VERS This edit indicates an invalid format and should be resolved by contacting your software vendor This information is not used for DMERC 11184 EPSDT SEG CRC The segment containing Early and Periodic Screening EXC MAX USE Diagnosis and Treatment EPSDT claims information exceeds maximum use When this information is reported only 1 occurrence per claim may be used This information is not used for DMERC 11185 EPSDT COND CRC02 The
283. m ZIP CODE When reporting address information the city state and zip MISSING code information must be included 10156 PAT HL HLO2 The code identifying the hierarchical level that this HL PARENT CODE relates to is missing MISSING This edit indicates an invalid format and should be resolved by contacting your software vendor This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 29 Edit Edit Description Element Edit Explanation Number Segment ID 10157 HL TYPE QUAL HLO3 The code identifying this hierarchical level is invalid INVALID Valid Value 23 Patient This edit indicates an invalid format and should be resolved by contacting your software vendor This information is not used for DMERC 10158 HL CHILD HLO4 The hierarchical child code is invalid CODE INVALID Valid Value 0 No subordinate HL segment in this HL structure This edit indicates an invalid format and should be resolved by contacting your software vendor This information is not used for DMERC 10159 PAT INFO PAT The segment providing patient information when different SEGMENT than the subscriber for this claim is missing This information MISSING is required when the patient is not the subscriber This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 30 Chapter Seven Edit Edit Descriptio
284. m EKG 10623 O2 TEST CR515 The qualifier indicating the finding of oxygen tests performed FINDINGS on patient in response to question 10 on CMN Form 484 2 is INVALID invalid for this line Valid Value 3 Erythrocythemia with a hematocrit greater than 56 percent 10624 CODE CRC01 The code used to indicate the type of certification being sent CATEGORY with this ambulance line is invalid INVALID Valid Value 07 Ambulance certification This information is not used for DMERC 10625 CERT COND CRC02 The ambulance certification condition code indicator is IND INVALID invalid for this line Valid Values N No Y Yes This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 121 Edit Number Edit Description Element Segment ID Edit Explanation 10626 COND CODE INVALID CRCO3 The code indicating the patient s condition is invalid for this ambulance line Valid Values 01 Patient was admitted to a hospital 02 Patient was bed confined before the ambulance service 03 Patient was bed confined after the ambulance service 04 Patient was moved by stretcher 05 Patient was unconscious or in shock 06 Patient was transported in an emergency situation 07 Patient had to be physically restrained 08 Patient had visible hemorrhaging 09 Ambulance service was medically necessary 60 Transportation was to the nearest facility Th
285. m may be used This information is not used for DMERC 10326 NOT USED 10327 ORIG REF NBR REF02 The original reference number is missing for this claim MISSING This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 54 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10328 CLIA NBR SEG REF The segment containing the Clinical Laboratory EXC MAX USE Improvement Amendment Number information exceeds maximum use When this information is reported only 1 occurrence per claim may be used This information is not used for DMERC 10329 NOT USED 10330 CLIA NBR REF02 The Clinical Laboratory Improvement Amendment number is MISSING missing for this claim This information is not used for DMERC 10331 REPRICER REF The segment containing the repriced claim number CLM NBR SEG information exceeds maximum use When this information is EXC MAX USE reported only 1 occurrence per claim may be used This information is not used for DMERC 10332 NOT USED 10333 REPRICER REF02 The repriced claim number is missing for this claim CLM NBR MISSING This information is not used for DMERC 10334 REPRICER REF The segment containing the adjusted repriced claim number ADJ CLM NBR information exceeds maximum use When this information is SEG EXC MAX reported only 1 occurrence per claim may be used USE This information is not used for DMER
286. make it into the system for processing In this case a front end edit will occur There is an entire chapter dedicated to each level of edits that may be received when transmitting claims electronically Each edit contains the edit number edit description and edit explanation to assist in correcting the error Chapter 7 contains the Implementation Guide edits Chapter 8 contains the Medicare edits and Chapter 9 contains the DMERC edits If you have questions about transmitting your claims please turn to Chapter 10 Contact Information This chapter will help you find the correct contact to answer your specific question Please read the options carefully to determine whom to contact for your specific issue To contact the EDI Department call 866 224 3094 toll free option 1 for customer service or option 2 for technical support Finally in the back of this manual is an Appendix which includes the DMERC Region D Companion Document Trading Partner Agreement followed by an EDI Glossary We are confident that you will be pleased with your decision to bill electronically and encourage you to stay up to date with the latest on EDI and utilize all possible options to maximize your business efficiency EDI Working together to meet your needs Chapter One Benefits of Billing Electronically When you elect to bill electronically you elect to open yourself up to many benefits of transmitting claims electronically The following provides a
287. mal channels When contacting the PET department please leave a message and briefly explain the purpose of your inquiry A PET representative will respond to you within 24 48 hours of your call Other DMERCs Region A Region B Region C HealthNow NY Inc AdminaStar Federal Inc Palmetto GBA Medicare DMERC PO Box 6800 PO Box 7078 PO Box 100141 Wilkes Barre PA 18733 6800 Indianapolis IN 46207 7078 Columbia SC 29202 3141 Phone 866 419 9458 toll free Phone 877 299 7900 toll free Phone 866 238 9650 toll free EDI 570 735 9429 EDI 800 470 9630 toll free EDI 866 749 4301 toll free www umd nycpic com www adminastar com www palmettogba com Other Contacts Statistical Analysis DMERC SADMERC Social Security Administration PO Box 100143 Phone 800 772 1213 Columbia SC 29202 3143 WWW SSQ gov Phone 877 735 1326 toll free www palmettogba com select Other Medicare Partners Medicare www medicare gov Centers for Medicare amp Medicaid Services CMS WWW CIMS ZOV National Supplier Clearinghouse NSC PO Box 100142 Columbia SC 29202 3142 Phone 866 238 9652 toll free www palmettogba com select Other Medicare Partners Region D DMERC EDI Manual Revised April 2003 HOW DO I FIND INFORMATION ON 5 zZ Z v T2 u rons E A amp 2 3 6 D O o ar a E 2 6 z b i CIGNA HealthCare gt A z o Medicare Administration Oo 5 O o O uw E 5 2 2 amp E g
288. mation for the ADD NAME pay to provider for this transaction exceeds maximum use SEGMENT EXC When this information is reported only 1 occurrence per MAX USE transaction may be used This information is not used for DMERC 10085 PAYTO ADR N3 The segment providing the pay to provider address for this SEGMENT EXC transaction exceeds maximum use When this information is MAX USE reported only 1 occurrence per transaction may be used This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 18 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10086 PAYTO C S Z N4 The segment providing city state and zip code information SEGMENT for the pay to provider for this transaction is missing When MISSING reporting address information the city state and zip code information must be included This information is not used for DMERC 10087 PAYTO CITY N401 The pay to provider city is missing for this transaction When MISSING reporting address information the city state and zip code information must be included This information is not used for DMERC 10088 PAYTO STATE N402 The pay to provider state abbreviation is missing for this ABR MISSING transaction When reporting address information the city state and zip code information must be included This information is not used for DMERC 10089 PAYTO ZIP N403 The pay to provider zip code is
289. mation is not used for DMERC 10242 ACC DATE DTP The segment providing the date of the accident for this claim SEGMENT EXC exceeds maximum use If this information is reported only MAX USE 10 occurrences per claim may be used 10243 NOT USED 10244 ACC DATE DTP02 The qualifier indicating the format used to report the FMT QUAL accident date for this claim is invalid INVALID Valid Values D8 Date expressed in format CCYYMMDD DT Date and time expressed in format CCYYMMDDHHMM Reauired if accident hour is known 10245 ACC DATE DTPO3 The accident date entered is invalid for this claim When INVALID entered this information must be entered ina CCYYMMDD FORMAT format 10246 ACC DATE DTPO3 The accident date entered is invalid for this claim When FUTURE DATE entered this information must not be greater than today s date 10247 ACC DTPO3 The accident date and time combination entered is invalid DATE TIME for this claim When entered this information must be INVALID FMT entered in a CCOYYMMDDHHMM format www cignamedicare com edi Revised April 2003 Page 44 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10248 LMP DT SEG DTP The segment providing the date of last menstrual period for EXC MAX USE this claim exceeds maximum use If this information is reported only 1 occurrence per claim may be used This information is not used for DMERC 10249 NOT USED 10250
290. mation must be entered in a CCYYMMDD format This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10875 ADJ OR PMT DTPO3 The line adjudication or payment date entered is invalid for FUTURE DATE this line When entered this information must not be greater INVALID than today s date This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10876 CANNOT SEND LQ The segment providing the CMN form identification number gt 5 2440 LQ information for this line exceeds maximum use When this SEGMENTS information is reported only 5 occurrences per claim may be used 10877 FORM TYPE LQO1 The qualifier identifying the type of form identification code CODE INVALID for this line is invalid Valid Values AS Form type code UT Health Care Financing Administration HCFA Durable Medical Equipment Regional Carrier DMERC Certificate of Medical Necessity CMN forms 10878 CERTIFICATE LQ02 The CMN form identification code is missing for this line NUMBER MISSING 10879 INV FRM02 The yes no value used to respond to the questions requiring RESPONSE a yes no response on all DMERC CMN s with the exception MUST BE Y N of CMN Form 484 2 is invalid for this line W OR BLANK Valid Values N No W Not applicable Y Yes 10880
291. maximum use When this SEGMENT EXC information is reported only 1 occurrence per transaction MAX USE may be used This information is not used for DMERC 10115 SUBSCRIBER N3 The segment providing the subscriber address for this claim ADR is missing The subscriber address must be submitted for SEGMENT each subscriber MISSING 10116 SUBSCRIBER N3 The segment providing the subscriber address for this claim ADR exceeds maximum use When this information is reported SEGMENT EXC only 1 occurrence per transaction may be used MAX USE 10117 SUBSCRIBER N4 The segment providing city state and zip code information C S Z for subscriber for this claim is missing When reporting SEGMENT address information the city state and zip code information MISSING must be included 10118 SUBSCRIBER N401 The subscriber city is missing for this claim When reporting CITY MISSING address information the city state and zip code information must be included 10119 SUBSCRIBER N402 The subscriber state abbreviation is missing for this claim STATE ABR When reporting address information the city state and zip MISSING code information must be included 10120 SUBSCRIBER N403 The subscriber zip code is missing for this claim When ZIP CODE reporting address information the city state and zip code MISSING information must be included 10121 SUBSCRIBER DMG The segment providing the subscriber demographic DEMO information is missing for this claim If the subsc
292. ment containing gt 3 PT COND patient condition information for ambulance services AMB SEGMENTS This information is not used for DMERC 11077 OTHER NM1 The segment containing the other subscriber name is SUBSCRIBER missing If you are sending other subscriber information this NAME segment is required SEGMENT MISSING This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare This information is used for Medigap secondary to Medicare claims and should not be submitted unless there is an approved Medigap policy held by this subscriber 11078 OTHER PAYER NM1 The segment containing the other payer name information is NAME missing for this claim If you are sending other payer SEGMENT information this segment is required MISSING This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare This information is used for Medigap secondary to Medicare claims and should not be submitted unless there is an approved Medigap policy held by this subscriber 11079 SVC FACILITY N3 The segment containing the service facility or oxygen test ADDRESS facility address is missing for this line If a place of service MISSING other than 12 home was used or if an oxygen test facility needs to be reported this segment is required
293. ms This column reports the number and This column reports the number and dollar amount of received Non Assigned dollar amount of transferred Non claims Assigned claims This column reports the number and dollar amount of accepted Assigned claims These row shows total dollar amount 3 This column reports the number and This column reports the number and Page 22 Chapter Six Report 716003 Error Listing The Error Listing report is included in the Electronic Report Package if there were one or more claims missing information or not meeting specified criteria and therefore not accepted into the processing system If on the Received Claims Listing report Report 716002 a CCN was not assigned to a claim and the ST column shows an R the Error Listing report will be generated The Error Listing report will identify the reason why a claim was rejected Refer to Chapters 7 8 and 9 for an explanation of the edit number received and to quickly identify what needs to be corrected You may receive multiple 716003 reports as a separate report is generated at each level in which the error occurred IN FG TX BP SP CL It is your responsibility to correct your errors and retransmit the file s Claims containing errors that were corrected and retransmitted for processing are NOT considered duplicate transmissions since the original claim was not accepted for processing These claims are considered new claims and may be transmitted electroni
294. mum use If this information is reported only 1 SEGMENT EXC occurrence per claim may be used MAX USE This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 52 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10312 NOT USED 10313 SVC AUTH REF The segment containing the service authorization exception CODE code information exceeds maximum use When this SEGMENT EXC information is reported only 1 occurrence per claim may be MAX USE used This information is not used for DMERC 10314 NOT USED 10315 SVC AUTH REF02 The code specifying the reason for service authorization CODE exception is invalid for this claim REASON INVALID Valid Values 1 Immediate urgent care 2 Services rendered in a retroactive period 3 Emergency care 4 Client as temporary Medicaid 5 Request from county for second opinion to recipient can work 6 Request for override pending 7 Special handling This information is not used for DMERC 10316 MED XOVER REF The segment containing the mandatory Medicare crossover SEG EXC MAX indicator information exceeds maximum use When this USE information is reported only 1 occurrence per claim may be used This information is used when a payer is submitting this claim to another payer and should not be submitted by the supplier This information is not used for DMERC 10317 NOT USED Region
295. n Element Edit Explanation Number Segment ID 10160 PAT REL TO PATO1 The qualifier indicating the patient s relationship to the INSURED insured is invalid for this subscriber CODE INVALID Valid Values 01 Spouse 04 Grandfather or grandmother 05 Grandson or granddaughter 07 Nephew or niece 09 Adopted child 10 Foster child 15 Ward 17 Stepson or stepdaughter 19 Child 20 Employee 21 Unknown 22 Handicapped dependent 23 Sponsored dependent 24 Dependent of a minor dependent 29 Significant other 32 Mother 33 Father 34 Other adult 36 Emancipated minor 39 Organ donor 40 Cadaver donor 41 Injured plaintiff 43 Child where insured has no financial responsibility 53 Life partner G8 Other relationship This information is not used for DMERC 10161 PAT DATE OF PATO5 The qualifier indicating the format used to report the DEATH FMT patient s date of death when the patient is not the subscriber QUAL INVALID for this claim is invalid Valid Value D8 Date expressed in CCYYMMDD format This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 31 Edit Edit Description Element Edit Explanation Number Segment ID 10162 PAT DATE OF PATO6 The patient s date of death when the patient is not the DEATH subscriber entered is invalid for this claim When entered INVA
296. n Number Segment ID 11146 N2 SEGMENT N2 The segment providing additional name information for the NOT ALLOWED other subscriber for this claim is invalid IN X12 VERSION This edit indicates an invalid format and should be resolved by contacting your software vendor This information is not used for DMERC 11147 N2 SEGMENT N2 The segment providing additional name information for the NOT ALLOWED other payer for this claim is invalid IN X12 VERSION This edit indicates an invalid format and should be resolved by contacting your software vendor 11148 N2 SEGMENT N2 The segment providing additional name information for the NOT ALLOWED rendering provider for this line is invalid IN X12 VERSION This edit indicates an invalid format and should be resolved by contacting your software vendor This information is not used for DMERC 11149 N2 SEGMENT N2 The segment providing additional name information for the NOT ALLOWED service facility location for this line is invalid IN X12 VERSION This edit indicates an invalid format and should be resolved by contacting your software vendor 11150 N2 SEGMENT N2 The segment providing additional name information for the NOT ALLOWED supervising provider for this line is invalid IN X12 VERSION This edit indicates an invalid format and should be resolved by contacting your software vendor This information is not used for DMERC 11151 N2 SEGMENT N2 The segment providing additional name information for the NOT ALLOWED order
297. n is invalid If PERCENT reported this amount cannot exceed 6 positions EXCEEDS MAXIMUM This information is not used by DMERC 11006 TERMS DISC CN105 The contract terms discount percent information is invalid If CANNOT reported this amount cannot exceed two positions to the HAVE gt 2 DEC right of the decimal point PLACES This information is not used by DMERC 11007 SALES TAX AMT02 The sales tax amount is invalid If reported this amount AMT EXCEEDS cannot exceed 18 positions MAXIMUM This information is not used for DMERC 11008 SALES TAX AMT02 The sales tax amount is invalid If reported this amount AMT CANNOT cannot exceed two positions to the right of the decimal point HAVE gt 2 DEC PLACES This information is not used for DMERC www cignamedicare com edi Revised April 2003 Front End Edits Page 177 Edit Edit Description Element Edit Explanation Number Segment ID 11009 APPROVED AMT02 The value entered as the approved amount is invalid If AMT EXCEEDS reported this amount cannot exceed 18 positions MAXIMUM This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 11010 APPROVED AMT02 The value entered as the approved amount is invalid If AMT CANNOT reported this amount cannot exceed two positions to the HAVE gt 2 DEC right of the decimal point PLACES
298. n the last name of that MISSING person If the responsible party was identified as a non person entity this element must contain the company name 10146 REP PAYEE NM104 The first name of the responsible party is missing for this FIRST NAME claim If you have specified the responsible party type to be MISSING a person this element must contain the first name of that person If the responsible party was identified as a non person entity this element is not used 10147 REP PAYEE N2 The segment providing additional responsible party name ADD NAME information for this claim exceeds maximum use When this SEGMENT EXC information is reported only 1 occurrence per transaction MAX USE may be used This information is not used for DMERC 10148 REP PAYEE N3 The segment providing the responsible party address for ADR this claim exceeds maximum use When sending SEGMENT EXC responsible party information this information can be MAX USE reported no more than one time 10149 NOT USED 10150 REP PAYEE N401 The responsible party s city is missing for this claim When CITY MISSING reporting address information the city state and zip code information must be included 10151 REP PAYEE N402 The responsible party s state abbreviation is missing for this STATE ABR claim When reporting address information the city state MISSING and zip code information must be included 10152 REP PAYEE N403 The responsible party s zip code is missing for this clai
299. ne Valid Value 0 Co pay exempt This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 114 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10597 DMERC CMN PWK The segment containing the DMERC CMN indicator IND EXC MAX information exceeds maximum use When this information is USE reported only 1 occurrence per line may be used 10598 ATTACH RPT PWKO1 The qualifier specifying the type of attachment for this line is TYPE CODE invalid INVALID Valid Value CT Certification 10599 ATTACH PWK02 The qualifier indicating the mode of transmission for the TRANS CODE documentation for this line is invalid INVALID Valid Values AB Previously submitted to payer AD Certification included in this claim AF Narrative segment included in this claim AG No documentation is required NS Not specified Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 115 Edit Edit Description Element Edit Explanation Number Segment ID 10600 UNIT BASIS CR101 The code used to indicate the measurement of the patient s MEASURE weight is invalid for this line This is only used when INVALID reporting information to justify extra ambulance services Valid Value LB Pound This information is not used for DMERC 10601 NOT USED 10602 AMBU TRANS CR103 The code used to indicate the
300. ne MISSING This information is not used for DMERC 10751 AMBUL PAT REF The segment containing the ambulatory patient group GRP EXC MAX information exceeds maximum use When this information is USE reported only 4 occurrences per line may be used This information is not used for DMERC 10752 NOT USED 10753 AMBUL PAT REF02 The ambulatory patient group number is missing for this line GRP MISSING This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 138 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10754 O2 FLOW REF The segment containing oxygen flow rate information RATE EXC exceeds maximum use When this information is reported MAX USE only 1 occurrence per transaction may be used 10755 NOT USED 10756 O2 FLOW REF02 The oxygen flow rate is invalid for this line RATE INVALID Valid Values 1 999 X if less than 1 10757 UPN EXC MAX REF The segment containing universal product number USE information exceeds maximum use When this information is reported only 1 occurrence per line may be used This information is not used for DMERC 10758 NOT USED 10759 UPN MISSING REF02 The universal product number is missing for this line This information is not used for DMERC 10760 SALES TAX AMT The segment providing the sales tax amount exceeds AMT EXC MAX maximum use If this information is reported only 1 USE oc
301. ne does not say COMPLETED SUCCESSFULLY the file transfer was not successful and you will need to either download or upload the file again The string of characters that follows START is the filename that the Stratus Network assigns to that transmission LOGOUT indicates the date and time your connection to the Stratus Network ended www cignamedicare con edi Revised June 2002 Page 28 Chapter Five Exit or Logoff 1 From the Mailbox Access Facility menu type 99 and press Enter You will be returned to the Main menu tetteteteeteteett Mailbox Access Facility tttttt tt tttttee User Id MBOO1A 0 Set User Defaults Current Settings 1 Change Data Type 2 Number of Files DATA TYPE RECEIVE_ANSITEST 3 List file names MAILBOX ND_XATO OUTBOUND 4 View a file 5 Download Get a file from Mailbox PROTOCOL PROMPT 7 Display Activity Log PRINTER_PAUSE NO FILE TYPE STREAM INITIAL MENU OPT NONE 99 Return to main menu Network 7 ENTER YOUR SELECTION 99_ 2 To logoff type 3 and press Enter CIGNA Gateway Service Tying in Customer s From Multiple Systems Mailbox Access Facility Download Activity Log Log off the System NEWS as of 01 19 01 Please Enter Choice 3 3 You have now successfully logged out of the Stratus Network You may now close your communications software Region D DMER
302. nformation the city name is required and must contain the city name for the address being reported Characters such as amp etc are allowed however we discourage use of these symbols e State When submitting address information the state abbreviation must be submitted When reported this element must contain a valid two position state code e Zip Code When submitting address information the postal zip code must be submitted when the address is within the United States or Province When submitted the zip code must be a valid five or nine digit code and must not contain all nines in the code e Country Code When reporting an address outside of the United States a valid country code must be submitted Dollar and Decimal Amounts Dollar and decimal amounts will be assumed to be whole numbers if no decimal is submitted When using the decimal it may not exceed two positions after the decimal point e Dollar Amounts In general dollar amounts being submitted to Medicare may not exceed 99 999 99 e Percentages When reporting percentages they must not exceed five positions including the decimal point i e 99 99 For information about code sets used within this transaction i e taxonomy codes state abbreviations country codes claim adjustment reason codes etc refer to Chapter C 1 of the ANSI X12N 837 v 4010 Implementation Guide www cignamedicare com edi Revised April 2003 Page 4 Chapter Seven Implementation G
303. nformation is not used for DMERC 10140 PAYER ID 2 REFO1 The qualifier for the payer secondary identification number QUAL INVALID information for this transaction is invalid Valid Values 2U Payer identification number FY Claim office number NF National Association of Insurance Commissioners TJ Federal taxpayer s identification number This information is not used for DMERC 10141 PAYER ID 2 REF02 The payer secondary identification number is missing for MISSING this transaction This information is not used for DMERC 10142 REP PAYEE NM1 The segment providing the responsible party name NAME information for this transaction exceeds maximum use SEGMENT EXC When this information is reported only 1 occurrence per MAX USE claim may be used 10143 REP PAYEE NM101 The qualifier identifying the responsibility party for this claim NAME QUAL is invalid INVALID Valid Value QD Responsible Party 10144 REP PAYEE NM102 The qualifier identifying the responsible party type is invalid ENTITY TYPE for this claim QUAL INVALID Valid Values 1 Person 2 Non person entity www cignamedicare com edi Revised April 2003 Page 28 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10145 REP PAYEE NM103 The last name or company name is missing for this claim If LAST ORG you have specified the responsible party type to be a NAME person this element must contai
304. ng T6 Claim does not contain enough information for re pricing This information is not used for DMERC 10779 POL COMP CODE INVALID HCP14 The repricer s policy compliance code is invalid for this line Valid Values 1 Procedure followed compliance 2 Not followed call not made non compliance call not made 3 Not medically necessary non compliance non medically necessary 4 Not followed other non compliance other 5 Emergency admit to non network hospital This information is not used for DMERC 10780 EXCEP CODE INVAILD HCP15 The repricer s exception code is invalid for this line Valid Values 1 Non network professional provider in network hospital 2 Emergency care 3 Services or specialist not in network 4 Out of service area 5 State mandates 6 Other This information is not used for DMERC 10781 REND PROV NAME EXC MAX USE NM1 The segment providing the rendering provider name information for this line exceeds maximum use When this information is reported only 1 occurrence per line may be used This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 143 Edit Edit Description Element Edit Explanation Number Segment ID 10782 ENTITY ID NM101 The qualifier identifying the rendering provider for this line is CODE INVALID invalid Valid Value
305. ng 837 claim transactions Any qualifiers submitted for Medicare processing not defined for use in Medicare billing will cause the claim or the transaction to be rejected e You may send up to four modifiers however the last modifier may not be considered The CIGNA Medicare processing system may only use the first three modifiers for adjudication and payment determination of claims e CIGNA Medicare will return the version of the 837 inbound transaction in GS08 Version Release Industry Identifier Code of the 997 e We suggest retrieval of the ANSI 997 functional acknowledgment files on or before the first business day after the claim file is submitted but no later than five days after the file submission e Compression of files is not supported for transmissions between the submitter and CIGNA Medicare Page 3 Revised 05 22 2002 Glossary A ANSI American National Standards Institute The highest level national standards organization that coordinates voluntary standards in the United States Does not develop standards but approves a standard when the sanctioned development organizations prove substantial agreement from those affected by the proposed standard American National Standards Institute ANSI Format Stream file format that uses transactions segments elements identifiers and delimiters All data lengths are variable in this format Specifications for the HIPAA compliant ANSI X12N version 4010 implementation guid
306. ng 837 transactions utilize delimiters from the following list gt and Submitting delimiters not supported within this list may cause an interchange transmission to be rejected e Only loops segments and data elements valid for the HIPAA Institutional or Professional Implementation Guides will be translated Submitting data not valid based on the Implementation Guide will cause files to be rejected e Only loops segments and data elements valid for the HIPAA Institutional or Professional Implementation Guides will be translated Non implementation guide data will not be sent for processing consideration e All dates that are submitted on an incoming 837 claim transaction should be valid calendar dates in the appropriate format based on the respective qualifier Failure to submit a valid calendar date will result in rejection of the claim or the applicable interchange transmission e Transaction Set Purpose Code BHT02 must equal 00 ORIGINAL e Claim or Encounter Indicator BHT06 must equal CH CHARGEABLE e CIGNA Medicare will only process one transaction type records group per interchange transmission a submitter must only submit one GS GE Functional Group within an ISA IEA Interchange e CIGNA Medicare will edit data submitted within the envelope segments ISA GS ST SE GE and IEA beyond the requirements defined in the Institutional or Professional Implementation Guides e CIGNA Medicare will r
307. ng software For formatting issues please contact your software vendor for instruction and assistance Segment and Element Element Name Functional Identifier Code Group Control Number Transaction Set Identifier Code Transaction Set Control Number Segment ID Code Segment Position Loop ID Number Element Description X12 code identifying the functional group being acknowledged For 837 will HC Functional group number as appears in the submitted GS06 Code identifying the transaction being acknowledged from the originally submitted STO1 l e for 837 it would be 837 Transaction set number as appears in the submitter ST02 Segment in which the error occurred Position of the segment The segments ordered within the transaction which segment it is ST would 1 and count each segment from there Number assigned to the loop Valid Values with Description www cignamedicare com edi Page 26 Chapter Six Segment and Element Element Description Valid Values with Description Segment Code identifying the error with Unrecognized segment ID segment name Syntax the named segment not complete or not a valid segment ID Error Code per X12 l e NM would get this error if it did not read NM1 Unexpected segment this would occur if segments came in out of order l e if a NM1 followed a CLM segment Mandatory segment missing if a segment is required by X12 and was not present
308. ng the other payer for this claim is CODE INVALID invalid This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare OR This information is used for Medigap secondary to Medicare claims and should not be submitted unless there is an approved Medigap policy held by this subscriber Valid Value PR Payer 10514 ENTITY TYPE NM102 The qualifier identifying the other payer type is invalid for QUALIFIER this claim INVALID This information is used for Medigap secondary to Medicare claims and should not be submitted unless there is an approved Medigap policy held by this subscriber OR This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare Valid Value 2 Non person entity 10515 OTH PAYER NM103 The company name is missing for this claim If the other LAST NAME payer was identified as a non person entity this element MISSING must contain the company name This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare OR This information is used for Medigap secondary to Medicare claims and should not be submitted unless there is an approved Medigap policy held by this subscriber
309. nless another payer adjudicated this claim prior to being submitted to Medicare This information is used for Medigap secondary to Medicare claims and should not be submitted unless there is an approved Medigap policy held by this subscriber 20104 OTHER SUBSCRIBER CITY NAME INVALID N401 The city indicated on this claim for the other insured s city is invalid Verify the first position of the name of the city does not contain a space This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare This information is used for Medigap secondary to Medicare claims and should not be submitted unless there is an approved Medigap policy held by this subscriber 20105 OTHER SUBSCRIBER STATE CODE INVALID N402 The state abbreviation indicated on this claim for the other insured s state is not a valid two character state abbreviation code This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare This information is used for Medigap secondary to Medicare claims and should not be submitted unless there is an approved Medigap policy held by this subscriber www cignamedicare com edi Revised April 2003 Page 18 Chapter Eight Edit Number EDIT DESCRIPTION Elem
310. not be used for processing e CIGNA Medicare will convert all lower case characters submitted on an inbound 837 file to upper case when sending data to the Medicare processing system Consequently data later submitted for coordination of benefits will be submitted in upper case DMERC Region D Companion Document Trading Partner Agreement e You must submit incoming 837 claim data using the basic character set as defined in Appendix A of the 837 Professional Implementation Guide In addition to the basic character set you may choose to submit lower case characters and the symbol from the extended character set Any other characters submitted from the extended character set will cause the interchange transmission to be rejected at the carrier translator e The subscriber hierarchical level HL segment must be in order from one by one 1 and must be numeric e Currency code CURO2 must equal USA e Diagnosis codes have a maximum size of five 5 Medicare does not accept decimal points in diagnosis codes e Total submitted charges CLM02 must equal the sum of the line item charge amounts SV 102 e Do not use Credit Debit card information to bill Medicare 2300 loop AMTOI MA and 2010BD loop e Service unit counts units or minutes cannot exceed 999 9 SV104 e For Medicare the subscriber is always the same as the patient SBRO2 18 SBRO9 MB The Patient Hierarchical Level 2000C loop is not used e The incomi
311. not contact you Errors reported on the 997 report should be addressed by the software vendor who provided your ANSI X12N software After you have received an Accepted message on the 997 report you have passed Phase I and your test claims will automatically move to Phase II During Phase II an Electronic Report Package will be generated and available to download from your Stratus mailbox within 2 hours The Electronic Report Package generated in Phase II is identical to the Electronic Report Package that will be generated during production For more information on the Electronic Report Packages refer to Chapter 6 of this manual Upon receipt of your Phase II results the EDI Department will contact you within 3 business days to review any errors you may have received and explain how to correct them You must have a 95 or higher acceptance rate in order to pass the Phase II of the testing process If you do not have a 95 acceptance rate you will need to re transmit the claims after correcting the errors Go back to Step 1 Note The acceptance rate is determined by counting all errors on a single claim as only one error regardless of the number of errors it may contain For example if you transmit a claim and it contains five errors it will only be counted as one error Note for software vendors billing services and clearinghouses You must test a minimum of 25 test claims with 25 different procedure codes The test claims should be repre
312. nother region we will automatically transfer the claim to the appropriate DMERC based on the beneficiary s address indicated on the claim Note In order for the claim to be processed by another DMERC you must have an EDI Enrollment Form on file with each DMERC for which the claim will be transferred www cignamedicare com edi Revised June 2002 Page 2 Chapter One Free electronic billing software and support The Centers for Medicare and Medicaid Services CMS mandates that all DMERCs provide and support a free billing software designed to build and transmit Medicare claims electronically DMERC Medicare Automated Claims System DMACS32 is a basic easy to use software package offered by the DMERC EDI Department MCM 3023 An upgrade or equivalent based on the HIPAA standard ANSI X12N 4010 format is scheduled for release in April 2002 Electronic Funds Transfer EFT This is an optional benefit available to both electronic and or paper billers Your payment checks will be direct deposited into your bank account and available two days after payment is disbursed Paper checks can take as long as one week to process MCM 3021 2 EDI Web site section This section has been developed specifically as a resource for potential and existing electronic billers You may access this section via the CIGNA Medicare Web site Point your browser to www cignamedicare com edi to access information on EDI products and services system updates getting s
313. nt level For example if the beneficiary s HICN was not included on the claim If an edit at this level occurs every claim for that beneficiary would have to be retransmitted www cignamedicare con edi Page 18 Chapter Six CL error occurred at the claim or service line level For example if the ordering provider s UPIN was not included on the claim If an error occurs at this level this claim would need to be corrected and retransmitted www cignamedicare com edi CARRIER 05655 PROGRAM X 8371600 REPORT 716002 CIGNA INC MEDICARE DM ERC RECEIVED CLAIMS LISTING SUBMITTER ID NAME D0869999 ANY BILLING COMPANY BILLING ID NAME 9999990001 SUPPLIER COM PANY PAY TO ID NAME SAME AS BILLING HICN PATIENT LAST NAME FIRST NAMEM PAT ACCT NBR FROM TO 999999999D SUBSCRIBER JOE L TEST1323 03212001 03212001 111100011A TRANSFER MY TEST1111 08152001 08152001 222200011B REJECTED TEST TEST2222 09012001 09012001 990000025C TRANSFER REJECTED C TEST4444 08012001 08012001 Claim Control Number assigned by CIGNA DMERC for all accepted claims Transfer and rejected claims do not contain a CCN HICN for the subscriber for this claim Patient Account Number assigned by the submitter supplier for this subscriber Status of this claim A Accepted R Rejected T Transferred RUN DATE 09 09 01 RUN TIME 6 48 32 PAGE 1 CCN BILLED AMT ST TX LVL 01252810001000 50 00 A 100 00 A B 75 00 R CL 142 25 RC CL Transferred to Thi
314. ntact 10039 SUBMITTER PER02 The submitter contact person s name is missing for this CONTACT transaction A contact name for the submitter must be NAME submitted with this transaction MISSING 10040 SUBMITTER PERO3 The qualifier identifying the type of contact information being CONTACT provided for the submitter is invalid for this transaction TYPE QUAL 1 INVALID Valid Values ED EDI access number EM E mail FX Facsimile TE Telephone 10041 SUBMITTER PERO5 The qualifier identifying the second type of contact CONTACT information being provided for the submitter is invalid for this TYPE QUAL 2 transaction INVALID Valid Values ED EDI access number EM E mail EX Telephone extension number FX Facsimile TE Telephone www cignamedicare com edi Revised April 2003 Page 12 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10042 SUBMITTER PERO7 The qualifier identifying the third type of contact information CONTACT being provided for the submitter is invalid for this TYPE QUAL 3 transaction INVALID Valid Values ED EDI access number EM E mail EX Telephone extension number FX Facsimile TE Telephone 10043 RECEIVER NM1 The segment providing name information for the receiver of NAME this transaction is missing This information is required on all SEGMENT DMERC transactions MISSING 10044 RECEIVER NM101 The qualifier id
315. ntifying the payer s identification QUALIFIER INVALID number for this claim is invalid Valid Value PI Payor Identification www cignamedicare com edi Revised April 2003 Page 6 Chapter Eight Edit Number EDIT DESCRIPTION Element D Edit Explanation 20035 PAYOR ADDRESS1 N301 The payer s address listed on this claim was entered in INVALID an invalid format Verify the first position of the address information does not contain a space 20036 PAYOR STATE N402 The state abbreviation indicated on this claim for the CODE INVALID payer s state is not a valid two character state abbreviation code 20037 PAYOR ZIP CODE N403 The zip code indicated on this claim for the payer s INVALID address was reported in an invalid format Verify the zip code contains only numeric data and is not all zeros or all nines and is either five or nine digits in length 20038 PAYOR COUNTRY N404 The country code indicated on this claim for the payer s CODE INVALID address is not a valid country code 20039 RESPONSIBLE NM103 The responsible party s last name was entered in an PARTY LAST NAME invalid format Verify the first position of the responsible INVALID party s last name is an alpha character and does not contain spaces Make sure the first three positions of the responsible party s last name are not any of the following MR MR DR DR JR or JR 20040 RESPONSIBLE NM104 The responsib
316. nts in error used if AK3 shows segment error Missing or invalid transaction set identifier STO1 must properly identify the transaction being sent l e 837 997 etc Missing or invalid transaction set control number SE02 or SE02 is missing or contains too many too few or invalid characters Authentication key name unknown Encryption key name unknown Requested service authentication or encrypted not available Unknown security recipient Incorrect message length encryption only Page 10 Chapter Six Element Name Segment and Element Transaction Set Syntax Error Code Transaction Set Syntax Error Code Transaction Set Syntax Error Code Transaction Set Syntax Error Code Element Description Used if multiple error codes are needed repeated values above Used if multiple error codes are needed repeated values above Used if multiple error codes are needed repeated values above Used if multiple error codes are needed repeated values above Valid Values with Description Message authentication code failed Unknown security originator Syntax error in decrypted text Security not supported will send this error when security information is sent ISA03 or ISA04 Transaction set control number not unique within the functional group If more than 1 transaction set ST SE is sent in 1 functional group GS GE each ST02 must be unique S3E security end segment missing for S3S security star
317. o QUIT gt z Receiving FILENAME will he scigna ml dO2 gt FxF_7 gt fxf gt SD_CATI gt MOO1AI_2001 04 03 000001 7 Place your PC in zmodem mode to send the file set options 32 bit CRC Data Streaming mode Press lt RETURN gt after transfer completion B000000027fed4 Region D DMERC EDI Manual Revised June 2002 Stratus Network User Guide Page 17 Mailbox Access Facility Menu Option 5 Download Get a File From Mailbox Using the download option you can receive your test or production electronic reports 997 Functional Acknowledgment reports and production ANSI 835 Remittance Notices 1 3 4 Enter the corresponding number of the file that you would like to download or q to quit 5 6 Mailbox Access Set User Defaults Change Data Type Number of Files List file names View a file Download Get a file from Mailbox Display Activity Log Return to main menu ENTER YOUR SELECTION 7 Facility Note Until a correct data type is selected option 5 will not appear as a menu option From the Mailbox Access Facility menu type 5 and press Enter FEEHAEEAA EE EEE EEE User Id MBOO1A Current Settings DATA TYPE RECEIVE _ANSITEST MAILBOX ND_XATO OUTBOUND PROTOCOL PROMPT FILE TYPE STREAM PRINTER_PAUSE NO INITIAL MENU OPT NONE Network 7 Check your Current Settings box and make sure your data type begins
318. o be a person this element MISSING must contain the last name of that person This information is not used for DMERC 10459 SUPER PROV NM104 The first name of the supervising provider is missing for this FIRST NAME claim If you have specified the supervising provider type to MISSING be a person this element must contain the first name of that person If the supervising provider was identified as a non person entity this element is not used This information is not used for DMERC 10460 ID CODE NM108 The qualifier identifying the supervising provider QUALIFIER identification number for this claim is invalid INVALID Valid Values 24 Employers Identification Number 34 Social Security Number XX National Provider Identifier This information is not used for DMERC 10461 ADD SUPER N2 The segment providing additional supervising provider name PROV NAME information for this claim exceeds maximum use When this EXC MAX USE information is reported only 1 occurrence per transaction may be used This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 81 Edit Edit Description Element Edit Explanation Number Segment ID 10462 SUPER PROV REF The segment containing additional supervising provider SEC ID EXC identification information exceeds maximum use When this MAX USE information is reported only 5 occurrences per claim may be used This informat
319. o the nearest facility This information is not used for DMERC 10629 COND CODE CRCO06 The qualifier indicating the patient s fourth condition is INVALID invalid for this ambulance line Valid Values 01 Patient was admitted to a hospital 02 Patient was bed confined before the ambulance service 03 Patient was bed confined after the ambulance service 04 Patient was moved by stretcher 05 Patient was unconscious or in shock 06 Patient was transported in an emergency situation 07 Patient had to be physically restrained 08 Patient had visible hemorrhaging 09 Ambulance service was medically necessary 60 Transportation was to the nearest facility This information is not used for DMERC 10630 COND CODE CRCO07 The qualifier indicating the patient s fifth condition is invalid INVALID for this ambulance line Valid Values 01 Patient was admitted to a hospital 02 Patient was bed confined before the ambulance service 03 Patient was bed confined after the ambulance service 04 Patient was moved by stretcher 05 Patient was unconscious or in shock 06 Patient was transported in an emergency situation 07 Patient had to be physically restrained 08 Patient had visible hemorrhaging Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 123 Edit Edit Description Element Edit Explanation Number Segment ID 09 Ambulance service
320. occurrence per claim may be used This information is not used for DMERC 10403 DISCIPLINE CR701 The qualifier identifying the discipline type code for home TYPE CODE health care plan information is invalid for this claim INVALID Valid Values Al Home health aide MS Medical social worker OT Occupational therapy PT Physical therapy SN Skilled nursing ST Speech therapy This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 70 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10404 HLTH CARE HSD The segment providing the health care services delivery SER DEL SEG information for this line exceeds maximum use When this EXC MAX information is reported only 3 occurrences per claim may be used This information is not used for DMERC 10405 QUANTITY HSDO1 The qualifier specifying the type of services being reported QUALIFIER for home health deliveries is not valid for this claim INVALID Valid Values VS Visits This information is not used for DMERC 10406 FREQUENCY HSDO03 The qualifier specifying the frequency of services being PERIOD QUAL reported for home health deliveries is not valid for this claim INVALID Valid Values DA Days MO Months Q1 Quarter time WK Week This information is not used for DMERC 10407 DUR OF VISITS HSDO5 The qualifier specifying the duration of visits being reported UNITS QUA
321. of the address INVALID information does not contain a space 20076 SERVICE N302 The service facility location or oxygen test facility FACILITY LAB additional address information listed on this claim was ADDDRESS2 entered in an invalid format Verify the first position of INVALID the address information does not contain a space 20077 SERVICE N401 The city indicated on this claim for the service facility FACILITY LAB CITY location or the oxygen test facility city is invalid Verify NAME INVALID the first position of the name of the city does not contain a space 20078 SERVICE N402 The state abbreviation indicated on this claim for the FACILITY LAB service facility or oxygen test facility state is not a valid STATE CODE two character state abbreviation code INVALID 20079 SERVICE N403 The zip code indicated on this claim for the service FACILITY LAB ZIP facility or oxygen test facility zip code was reported in CODE INVALID an invalid format Verify the zip code contains only numeric data and is not all zeros or all nines and is either five or nine digits in length 20080 SERVICE N404 The country code indicated on this claim for the service FACILITY LAB facility or oxygen test facility country is not a valid COUNTRY INVALID country code 20081 SERVICE FACILITY REFO1 The qualifier for the service facility location or oxygen REF ID QUALIFIER test facility s secondary identification number INVALID information for this claim is invalid Valid Val
322. of the decimal CANNOT HAVE point gt 2 DEC This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 171 Edit Edit Description Element Edit Explanation Number Segment ID 10963 COB PT PD AMT02 The value representing the primary payer s patient paid AMT EXCEEDS amount exceeds 18 positions MAXIMUM This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10964 COB PT PD AMT02 The value representing the primary payer s patient paid AMT CANNOT amount exceeds two positions to the right of the decimal HAVE gt 2 DEC point This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10965 COB TAX AMT AMT0O2 The value representing the primary payer s tax amount EXCEEDS exceeds 18 positions MAXIMUM This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10966 COB TAX AMT AMT02 The value representing the primary payer s tax amount CANNOT HAVE exceeds two positions to the right o
323. of the response cannot contain a space 40071 QUESTION FRM04 The date entered on this CMN is invalid Verify the date is an RESPONSE actual date has 19 or 20 as the century and is entered ina INVALID DATE CCYYMMDD format www cignamedicare com edi Revised April 2003 Page 8 Chapter Nine Edit EDIT Element Edit Explanation Number DESCRIPTION ID 40072 QUESTION FRMO05 The percentage amount entered is invalid Verify information RESPONSE submitted is numeric and is not greater than 99 99 INVALID PERCENT 40073 DATES OF DTPO3 The date of service entered for this line is invalid Verify the SERVICE HCPCS or NDC is effective for the date of service submitted EXCEED MPR for this line DATES 40074 CMN INITIAL DTPO3 The date entered as the initial date on the CMN submitted DATE INVALID with this line is invalid Verify the date entered as the initial date is not greater than today s date Region D DMERC EDI Manual Revised April 2003 Front End Edits DMERC Page 9 Edit EDIT Element Edit Explanation Number DESCRIPTION ID 40075 CMN INDICATOR PWK The segment containing the CMN indicator is missing This is MISSING a required segment for all lines containing a CMN 40076 CMN FORM LQ The segment containing the CMN form number is missing IDENTIFIER This is a required segment for all lines containing a CMN MISSING 40077 CMN FORM FRM Th
324. on e The type of file transmitted based on data sent in the ANSI X123N 837 transaction T Test P Production e Contact information for the entity that transmitted the file Region D DMERC EDI Manual November 2001 CARRIER 05655 CIGNA INC RUN DATE 09 09 01 PROGRAM X8371600 MEDICARE DM ERC ee RUN TIME 6 48 32 REPORT 7l Pree SUBMITTER REPORTS COVER PAGE PAGE 1 ON THIS DATE 09 09 2001 WE RECEIVED THE SUBMITTED DATA AS DESCRIBED ON THE ATTACHED REPORTS SUBMISSION DATE AND TIME 090901 see SUBMITTER ID D08699999 NAME ANY BILLING COMPANY ADDRESS 1850 SEXAMPLE BLVD SUITE 100 CITY STATE ZIP MY CITY ST 99999 CONTACT SUBMITTER CONTACT INTERCHANGE SENDER ID MBOO1A CONTROL NUMBER 1234567830 J G TEST OR PROD P ACKNOWLEDGE o H EDI NBR pe PHONE 866 244 309 EXT FAX EMAIL EDI CONTACT SUPPLIER COM Name of Carrier issuing this report VMS Report number unique to each Test Production indicator as submitted on the incoming report 837 transaction Report Title Submission date and time as reported on EDI number Submitter contact information not used for the incoming 837 transaction CIGNA DMERC Blank indicates no information to display C Date report was generated by claim Interchange control number ISA13 as Information contained in this section with the exception processing system submitted on the incoming 837 of Submitter Name and Address information is what was transaction originally submi
325. on causing the REAS 2 need for replacement lenses or frames is invalid for this INVALID claim Valid Values L1 General standard of 20 degree or 5 diopter sphere Or cylinder change met L2 Replacement due to loss or theft L3 Replacement due to breakage or damage L4 Replacement due to patient preference L5 Replacement due to medical reason This information is not used for DMERC 10381 VIS COND CRCO05 The qualifier indicating the third condition causing the need REAS 3 for replacement lenses or frames is invalid for this claim INVALID Valid Values L1 General standard of 20 degree or 5 diopter sphere Or cylinder change met L2 Replacement due to loss or theft L3 Replacement due to breakage or damage L4 Replacement due to patient preference L5 Replacement due to medical reason This information is not used for DMERC 10382 VIS COND CRC06 The qualifier indicating the fourth condition causing the need REAS 4 for replacement lenses or frames is invalid for this claim INVALID Valid Values L1 General standard of 20 degree or 5 diopter sphere Or cylinder change met L2 Replacement due to loss or theft L3 Replacement due to breakage or damage L4 Replacement due to patient preference L5 Replacement due to medical reason This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 66 Chapter Seven Edit Edit D
326. on information is missing from this claim ID MISSING This information is not used for DMERC 10578 REF ID REFO1 The qualifier for the other payer supervising provider QUALIFIER secondary identification number information for this claim is INVALID invalid This information is used when a payer is submitting this claim to another payer and should not be submitted by the supplier Valid Values 1B Blue Shield provider number 1C Medicare provider number 1D Medicaid provider number El Employer s Identification Number G2 Provider commercial number N5 Provider plan network identification number This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 110 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10579 OTH PAY REF02 The other payer supervising provider secondary SUPER PROV identification is missing for this line ID MISSING This information is used when a payer is submitting this claim to another payer and should not be submitted by the supplier This information is not used for DMERC 10580 SERVICE LINE LX The segment providing the service line sequence DOES NOT information is missing Each DMERC claim must contain at EXIST least one occurrence of this segment 10581 SERVICE LINE LX The segment containing service line sequence information EXC MAX USE exceeds maximum use Each DMERC claim can not e
327. on is not used for DMERC 10092 PAYTO PROV ID 2 MISSING REF02 The pay to provider secondary supplier number is missing for this transaction This information is not used for DMERC 10093 SBR HL PARENT CODE MISSING HLO2 The code identifying the hierarchical level HL that this HL relates to is missing This edit indicates an invalid format and should be resolved by contacting your software vendor 10094 HL TYPE QUAL INVALID HLO3 The code identifying this hierarchical level is invalid Valid Value 22 Subscriber This edit indicates an invalid format and should be resolved by contacting your software vendor www cignamedicare com edi Revised April 2003 Page 20 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10095 HL CHILD HLO4 The hierarchical child code is invalid CODE INVALID Valid Values 0 No subordinate HL segment in this hierarchical structure 1 Additional subordinate HL data segment in this hierarchical structure This edit indicates an invalid format and should be resolved by contacting your software vendor 10096 SUBSCRIBER SBR The segment providing subscriber information for this claim INFO is missing This information is required on all DMERC SEGMENT claims MISSING 10097 PAYER RESP SBRO1 The qualifier indicating the responsibility of this payer CODE INVALID Medicare in relation to ot
328. on number is invalid Valid values 24 Employer s identification number 34 Social Security Number XX National Provider Identifier 20181 SUPERVISING PROV ID QUAL INVALID NM108 The qualifier used to indicate the supervising provider s primary identification number is invalid Valid values 24 Employer s identification number 34 Social Security Number XX National Provider Identifier This information is not used for DMERC 20182 REND PROV ID QUAL INVALID NM108 The qualifier used to indicate the rendering provider s primary identification number for this line is invalid Valid values 24 Employer s identification number 34 Social Security Number XX National Provider Identifier This information is not used for DMERC 20183 PURCH SERV PROV ID QUAL INVALID NM108 The qualifier used to indicate the purchased service provider s primary identification number for this line is invalid Valid values 24 Employer s identification number 34 Social Security Number XX National Provider Identifier This information is not used for DMERC 20184 SERVICE FACILITY ID QUAL INVALID NM108 The qualifier used to indicate the service facility s primary identification number for this line is invalid Valid values 24 Employer s identification number 34 Social Security Number XX National Provider Identifier
329. ons about the testing process or require assistance please give our office a call at 866 224 3094 toll free Please have your submitter ID number and your logon ID available when contacting the EDI Department Region D DMERC EDI Manual November 2001 Loops If you receive errors in testing the loop names listed on the report are identified below Header Billing Pay to Provider Loop Description 1000A Submitter Name 1000B Receiver Name 2000A Billing Pay To Provider Hierarchical Level 2010AA Billing Provider Name 2010AB Pay To Provider Name 2000B Subscriber Hierarchical 2010BA Subscriber Name 2010BB Payer Name poe ooo Claim Information Loop Description 2300 Claim Information 2305 Home Health Care Plan Information 2310A Referring Provider Name 2310B Rendering Provider Name 2310C Purchased Service Provider Name 2310D Service Facility Location 2310E Supervising Provider Name Testing Page 3 www cignamedicare com edi Page 4 Chapter Four Other Subscriber and Payer Information 2320 Other Subscriber Information 2330A Other Subscriber Name 2330B Other Payer Name 2330C Other Payer Patient Information Service Line 2400 Service Line 2420A Rendering Provider Name 2420B Purchased Service Provider 2420C Service Facility Location 2420D Supervising Provider Name 2420E Ordering Provider Name 2420F Referring Provider Name 2420G Other Payer Prior Authorization or Referral Numbe
330. or DMERC www cignamedicare com edi Revised April 2003 Page 42 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10229 CURRENT ILL DTPO3 The onset of current illness or symptom date entered is DT INVALID invalid for this claim When entered this information must be FMT entered in a valid CCYYMMDD format This information is not used for DMERC 10230 CURRENT ILL DTPO3 The onset of current illness date entered is invalid for this DT FUTURE DT claim When entered this information must not be greater than today s date This information is not used for DMERC 10231 ACUTE MAN DTP The segment providing the acute manifestation for this claim DT SEG EXC exceeds maximum use If this information is reported only 5 MAX USE occurrences per claim may be used This information is not used for DMERC 10232 ACUTE MAN DTP The segment providing the acute manifestation for this claim DT SEG is missing When providing information for spinal MISSING manipulation this information must be sent This information is not used for DMERC 10233 NOT USED 10234 ACUTE MAN DTP02 The qualifier indicating the format used to report the acute DT FMTQ manifestation date for this claim is invalid INVALID Valid Value D8 Date expressed in format CCYYMMDD This information is not used for DMERC 10235 ACUTE MAN DTPO3 The acute manifestation date entered is invalid for this DT INVALID claim When ente
331. or DMERC 11087 CONTRACT CN103 The value entered as the amount to be the contract amount AMN gt 2 in invalid This amount cannot contain more than 2 positions DECIMALS to the right of the decimal point This information is not used for DMERC 11088 NOT USED 11089 TOTAL CLAIM CLM02 The value representing the total claim charges for this claim CHARGE is missing This is required information on every DMERC AMOUNT claim MISSING 11090 TRANSPORT CR105 The value representing the ambulance transport distance is DISTANCE missing MISSING This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 188 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 11091 TREATMENT CR207 The value representing the count of treatments in this period PERIOD is missing from this claim COUNT MISSING This information is not used for DMERC 11092 LINE ITEM V102 The charge for this line item is missing For DMERC claims CHARGE this is required information AMOUNT MISSING 11093 SERVICE UNIT SV104 The value representing the unit of service is missing for this COUNT line For DMERC claims this is required information MISSING 11094 TRANSPORT CR105 The value representing the ambulance transport distance is DISTANCE missing MISSING This information is not used for DMERC 11095 TREATMENT CR202 The total number of treatments in this chiropr
332. or home health deliveries is not valid for this line INVALID Valid Value VS Visits This information is not used for DMERC 10769 FREQ PERIOD HSDO3 The qualifier specifying the frequency of services being INVALID reported for home health deliveries is not valid for this line Valid Values DA Days MO Months Q1 Quarter WK Week This information is not used for DMERC 10770 DUR OF HSD05 The qualifier specifying the duration of visits being reported VISITS UNITS for home health deliveries is not valid for this line INVALID Valid Values 7 Day 34 Month 35 Week This information is not used for DMERC 10771 DUR OF VIS HSDO6 The number of visits for home health deliveries is missing UNITS for this line MISSING This information is not used for DMERC 10772 PATTERN HSD07 The qualifier indicating the pattern code for visits being CODE INVALID reported for home health deliveries is not valid for this line Valid Values www cignamedicare com edi Revised April 2003 Page 140 Chapter Seven Edit Edit Description Number Element Segment ID Edit Explanation 1 1st week of the month 2 2nd week of the month 3 3rd week of the month 4 4th week of the month 5 5th week of the month 6 1st amp 3rd weeks of the month 7 2nd amp 4th weeks of the month A Monday through Friday B Monday through Saturday C Monday through Sunday D Monday E Tuesday F Wednesday
333. ormat used to report the date FORMAT shipped for this line is invalid QUALIFIER INVALID Valid Value D8 Date expressed in format CCYYMMDD This information is not used for DMERC 10694 SHIPPED DTP03 The shipped date entered is invalid for this line When DATE INVALID entered this information must be entered in a valid CCYYMMDD format This information is not used for DMERC 10695 SHIPPED DTP03 The shipped date entered is invalid for this line When DATE FUTURE entered this information must not be greater than today s DATE date This information is not used for DMERC 10696 SYMPT ILLNES DTP The segment providing the onset of current symptom or S DT EXC MAX illness date for this line exceeds maximum use When this USE information is reported only 1 occurrence per line may be used This information is not used for DMERC 10697 NOT USED 10698 DTE TIME PER DTP02 The qualifier indicating the format used to report the onset of FORMAT current symptom or illness date for this line is invalid QUALIFIER INVALID Valid Value D8 Date expressed in format CCYYMMDD This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 131 Edit Edit Description Element Edit Explanation Number Segment ID 10699 SYMPT ILLNES DTPO3 The onset of current symptom or illness date entered is S DATE invalid for this line When entered this information must be INVALID entered
334. ormation is not used for DMERC 10421 REF PROV REF The segment containing additional referring provider SEC ID EXC identification information exceeds maximum use When this MAX USE information is reported only 5 occurrences per claim may be used This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 74 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10422 REF ID REFO1 The qualifier for the referring provider secondary QUALIFIER identification number information for this claim is invalid INVALID Valid Values OB State license number 1B Blue Shield provider number 1C Medicare provider number 1D Medicaid provider number 1G Provider UPIN number 1H CHAMPUS identification number El Employer s Identification Number G2 Provider commercial number LU Location number N5 Provider plan network identification number SY Social Security Number this may not be used for Medicare X5 State industrial accident provider number This information is not used for DMERC 10423 REF PROV REF02 The referring provider secondary identification is missing for SEC ID this claim MISSING This information is not used for DMERC 10424 REND PROV NM1 The segment providing the rendering provider name NAME EXC information for this claim exceeds maximum use When this MAX USE information is reported only 1 occurrence per claim may be use
335. ot used for DMERC 10538 ENTITY ID NM101 The qualifier identifying the other payer patient for this claim CODE INVALID is invalid This information is used when a payer is submitting this claim to another payer and should not be submitted by the supplier Valid Value QC Patient Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 101 Edit Edit Description Element Edit Explanation Number Segment ID 10539 ENTITY TYPE NM102 The qualifier identifying the other payer patient type is QUALIFIER invalid for this claim INVALID This information is used when a payer is submitting this claim to another payer and should not be submitted by the supplier Valid Value 1 Person 10540 PATIENT LAST NM103 The last name is missing for this claim If you have specified NAME the other payer patient type to be a person this element MISSING must contain the last name of that person This information is used when a payer is submitting this claim to another payer and should not be submitted by the supplier 10541 ID CODE NM108 The qualifier identifying the other payer s patient QUALIFIER identification number for this claim is invalid INVALID This information is used when a payer is submitting this claim to another payer and should not be submitted by the supplier Valid Value MI Member identification number 10542 REF ID REFO1 The qualifier for the other payer patient secondary QUALIFIE
336. ot used for DMERC 10917 PRICING RATE HCP05 The value representing the claim repriced pricing rate EXCEEDS exceeds 9 positions MAXIMUM This information is not used for DMERC 10918 PRICING RATE HCP05 The value representing the claim repriced pricing rate CANNOT HAVE exceeds two positions to the right of the decimal point gt 2 DEC PLACES This information is not used for DMERC 10919 APPR APG HCPO07 The value representing the claim repriced approved APG AMT PRICING amount exceeds 18 positions EXCEEDS MAXIMUM This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 165 Edit Edit Description Element Edit Explanation Number Segment ID 10920 APPR APG HCPO07 The value representing the claim repriced approved APG AMT PRICING amount exceeds two positions to the right of the decimal CANNOT HAVE point gt 2 DEC This information is not used for DMERC 10921 NUMBER OF HSD02 The value representing the health care services delivery VISITS number of visits exceeds 15 positions EXCEEDS MAXIMUM This information is not used for DMERC 10922 NUMBER OF HSD02 The value representing the health care services delivery VISITS number of visits cannot contain a decimal point CANNOT HAVE DECIMAL This information is not used for DMERC 10923 MODULUS HSD04 The value representing the health care services delivery AMT EXCEEDS sampling frequency exceeds six posi
337. other insurance s or through deductible requirements e Claims electronically transferred to another DMERC for processing Note These claims do not display after 45 days of the transmission e Pending claims Note These are claims that have not been resolved or have not processed completely Pending claims information This function of CSI gives more detailed information about pending claims including the check date and estimated mailing date The pending claims screen does not include information on a claim if a check for that claim has already been mailed or if the claim has been denied Assigned pending claims fall into three categories 1 Claims waiting for information from the Common Working File CWP i e grandfathered Certificates of Medical Necessity CMNs or patient eligibility before they can be processed 2 Claims that have been processed but the check has not been mailed 3 Claims which require additional information or review to complete processing such as medical or utilization review and or development letters www cignamedicare con edi Page 2 Chapter Two Hours of operation and support CSI is available Monday through Saturday from 7 00 a m to 6 00 a m ET For questions about the software and or about transmitting claims contact the EDI Department between the hours of 8 00 a m and 5 00 p m MT Accessing CSI To access CSI AT amp T Passport for Windows communications software is available for Region D
338. pecific edits 40XXX DMERC specific edits Though these edits occur at separate levels they are all reported to you on the same error report For examples and for an explanation of the error reports refer to chapter 6 of this manual Key to Manual NOT USED These edits are currently not used but may be added at a later date www cignamedicare com edi Revised April 2003 Page 2 Chapter Seven General Guidelines We have provided some general guidelines for entering data Due to the variety of software available to DMERC submitters we can only provide the requirements as set forth by the ANSI X12N 837 v 4010 Implementation Guide and CMS requirements For data entry assistance please consult your software program s user manual or your software vendor The ANSI X12N 837 v 4010 Implementation Guide may be downloaded free of charge from www wpc edi com The Implementation Guide will provide valid qualifier values data requirements and provide information how to obtain code sources including state abbreviations zip codes taxonomy codes procedure codes etc Dates e Asa general rule all dates with the exception of the interchange creation date if entered by the submitter must be reported using a CCYYMMDD format where CC Century YY Year MM Month DD Day e When spanning dates for dates of service it must be reported as CCYYMMDD CCYYMMDD including the hyphen e When reporting a date time combination the CCYYMMDDH
339. planation Number Segment ID 10057 BILL PROV NM101 The qualifier identifying the billing provider for this NAME QUAL transaction is invalid INVALID Valid Value 85 Billing Provider 10058 BILL PROV NM102 The qualifier identifying the billing provider type is invalid for ENTITY TYPE this transaction QUAL INVALID Valid Values 1 Person 2 Non Person Entity 10059 BILL PROV NM103 The last name or company name is missing for this LAST ORG transaction If you have specified the billing provider type to NAME be a person this element must contain the last name of that MISSING person If the billing provider was identified as a non person entity this element must contain the company name 10060 BILL PROV NM104 The first name of the billing provider is missing for this FIRST NAME transaction If you have specified the billing provider type to MISSING be a person this element must contain the first name of that person If the billing provider was identified as a non person entity this element is not used 10061 BILL PROV ID NM108 The qualifier identifying the billing provider identification NUMBER number for this transaction is invalid QUAL INVALID Valid Values 24 Employer s Identification Number 34 Social Security Number XX Health Care Financing Administration National Provider Identifier 10062 BILL PROV N2 The segment providing additional name information for the ADD NAME billing provider for this transaction exceeds maximum
340. plementation Guide IG edits to ensure electronic files meet the HIPAA standard The IG edits and descriptions are contained in Chapter 7 The Medicare edits are in Chapter 8 and the DMERC specific edits and descriptions are included in this chapter To allow you to quickly identify the level in which the error occurred the edits are numbered as follows 10XXX Implementation Guide edits 20XXX Medicare specific edits 40XXX DMERC specific edits The DMERC specific edits will validate data requirements specific to DMERC such as DMERC HCPCS NDC codes proper dates places of service and CMN data requirements Since our system processes both DMERC and Part B Medicare claims a separate level for editing DMERC requirements has been developed For your convenience we have indicated data elements in this section that are not used for DMERC If you receive an edit on data that is not used for DMERC and the information is not needed for another payer please remove the erroneous data and resubmit the file If the data is needed for another payer please correct the claim and retransmit Key to Manual NOT USED These edits are currently not used but may be added at a later date www cignamedicare com edi Revised April 2003 Page 2 Chapter Nine Edit EDIT Element Edit Explanation Number DESCRIPTION ID 40001 PATIENT DATE PATO6 The date entered as the subscriber s date of death is invalid OF DEATH
341. product or QUALIFER service code is invalid for this line INVALID Valid Values HC Health Care Financing Administration Common Procedural Coding System HCPCS codes IV Home Infusion EDI Coalition HIEC product service code N1 National drug code in 4 4 2 format N2 National drug code in 5 3 2 Format N3 National drug code in 5 4 1 Format N4 National drug code in 5 4 2 Format ZZ Mutually defined This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 159 Edit Edit Description Element Edit Explanation Number Segment ID 10869 PAID SVC SVD05 The line adjudication information paid service unit count is COUNT invalid for this line MISSING This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10870 GROUP ADJ CAS01 The qualifier specifying the claim adjustment group code for REASON the adjustments being reported is invalid for this line CODE INVALID Valid Values CO Contractual obligations CR Correction and reversals OA Other adjustments PI Payer initiated reductions PR Patient responsibility This information is used for Medicare Secondary Payer claims and should not be subm
342. qualifier identifying the ordering physician identification CODE number for this line is invalid QUALIFIER INVALID Valid Values 24 Employer s Identification Number 34 Social Security Number XX Health Care Financing Administration National Provider Identifier This information is not used for DMERC 10831 CANNOT SEND N2 The segment providing additional ordering provider s name gt 1 ADDTL ORD information for this line exceeds maximum use When this PROV NAME information is reported only 1 occurrence per transaction SEG may be used This information is not used for DMERC 10832 CANNOT SEND N3 The segment providing the ordering provider address for this gt 1 ORD PROV line exceeds maximum use When this information is ADDR reported only 1 occurrence per transaction may be used SEGMENT This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 152 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10833 ORD PROV N401 The ordering provider s city is missing for this line When ADDR reporting address information the city state and zip code MISSING information must be included This information is not used for DMERC 10834 ORD PROV N402 The ordering provider s state abbreviation is missing for this STATE CODE line When reporting address information the city state and MISSING zip code information must be included This
343. qualifier indicating an EPSDT referral was given to the CODE INVALID patient is invalid Valid Values N No Y Yes This information is not used for DMERC 11186 EPSDT COND CRCO03 The qualifier indicating the type of EPSDT referral is invalid REAS 1 for this claim INVALID Valid Values AV Available Not Used The patient refused referral NU Not used This indicator must be used when the submitter answers N in CRCO2 S2 Under Treatment ST New Services Requested This information is not used for DMERC 11187 COND IND CRCO03 You have indicated an EPSDT referral was not given to this MUST BE NU patient however the value used to indicate an EPSDT was WHEN NO not used is missing from this claim REF GIVEN This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 201 Edit Edit Description Element Edit Explanation Number Segment ID 11188 EPSDT COND CRC04 The qualifier indicating the type of EPSDT referral is invalid REAS 2 for this claim INVALID Valid Values AV Available Not Used The patient refused referral NU Not used This indicator must be used when the submitter answers N in CRC02 S2 Under Treatment ST New Services Requested This information is not used for DMERC 11189 EPSDT COND CRCO05 The qualifier indicating the type of EPSDT referral is invalid REAS 3 for this claim INVALID Valid Values
344. r 2430 Line Adjudication Information 2440 Form Identification Code Region D DMERC EDI Manual November 2001 Testing Page 5 Frequently Asked Questions about Testing For your convenience we have provided some common questions about testing and the testing process as received by the EDI Department Q A How long does it take to complete the testing process The testing process can be completed in as little as three working days if both phases are passed without errors on the first transmission Otherwise the testing process should take no longer than seven working days The time is dependent on how many errors you receive in both the Phase I and Phase II of the testing process as well as how long it takes you to fix your errors and retransmit the claims Isentin a test two weeks ago Why haven t received a response on my results If you have not received a telephone call from the CIGNA Medicare EDI Department on Phase II of your test that usually indicates that you never passed Phase I see step 2 on page 1 of this chapter If you have errors reported on the 997 Functional Acknowledgement report you must correct the errors and retransmit them into the test facility Continue to do this step until your 997 report indicates your transaction was accepted Once you receive this message your file will move into Phase II of the testing process CIGNA Medicare will receive a report of the results of your Phase II test and
345. r other payer is invalid This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare Valid Values 01 Spouse 04 Grandfather or grandmother 05 Grandson or granddaughter 07 Nephew or niece 10 Foster child 15 Ward 17 Stepson or stepdaughter 18 Self 19 Child 20 Employee 21 Unknown 22 Handicapped dependent 23 Sponsored dependent 24 Dependent of a minor dependent 29 Significant other 32 Mother 33 Father 36 Emancipated minor 39 Organ donor 40 Cadaver donor 41 Injured plaintiff 43 Child where insured has no financial responsibility 53 Life partner G8 Other relationship Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 83 Edit Edit Description Element Edit Explanation Number Segment ID 10467 INS TYPE SBR05 The qualifier identifying the type of insurance coverage CODE INVALID primary to Medicare for this subscriber is invalid This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare Valid Values AP Auto insurance policy C1 Commercial CP Medicare conditionally primary GP Group policy HM Health Maintenance Organization HMO IP Individual policy LD Long term policy LT
346. r DMERC 10488 NOT USED 10489 COB TOT CLM AMT The segment providing the other payer total claim before BEFORE TAX taxes amount exceeds maximum use If this information is EXC MAX USE reported only 1 occurrence per claim may be used This information is not used for DMERC 10490 NOT USED 10491 SUB DEMOG DMG The segment providing the other insured s demographic INFO MISSING information is missing for this claim This segment is required when patient is different than the insured for the primary payer This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare This information is used for Medigap secondary to Medicare claims and should not be submitted unless there is an approved Medigap policy held by this subscriber 10492 DTE TM PER DMG01 The qualifier indicating the format used to report the QUALIFIER insured s date of birth is invalid for this claim This INVALID information is required when the patient is different than the insured for the primary payer This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare This information is used for Medigap secondary to Medicare claims and should not be submitted unless there is an approved Medigap policy held by this subscriber Valid Value D8 Date expresse
347. r this claim is invalid INVALID Valid Values OB State license number 1A Blue Cross provider number 1B Blue Shield provider number 1C Medicare provider number 1D Medicaid provider number 1G Provider UPIN Number 1H CHAMPUS identification number G2 Provider commercial number LU Location number N5 Provider plan network identification number TJ Federal taxpayer s identification number X4 Clinical Laboratory Improvement Amendment Number X5 State industrial accident provider number 10455 SUPER PROV NM1 The segment providing the supervising provider name NAME EXC information for this claim exceeds maximum use When this MAX USE information is reported only 1 occurrence per claim may be used This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 80 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10456 ENTITY ID NM101 The qualifier identifying the supervising provider for this CODE INVALID claim is invalid Valid Value DQ Supervising physician This information is not used for DMERC 10457 ENTITY TYPE NM102 The qualifier identifying the supervising provider type is QUALIFIER invalid for this claim INVALID Valid Value 1 Person This information is not used for DMERC 10458 SUPER PROV NM103 The last name is missing for this claim If you have specified LAST NAME the supervising provider type t
348. red this information must be entered in a FMT CCYYMMDD format This information is not used for DMERC 10236 ACUTE MAN DTPO3 The acute manifestation date entered is invalid for this DT FUTURE DT claim When entered this information must not be greater than today s date This information is not used for DMERC 10237 SIMILAR ILL DT DTP The segment providing the onset of similar illness or SEG EXC MAX symptom date exceeds maximum use If this information is USE reported only 10 occurrences per claim may be used This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 43 Edit Edit Description Element Edit Explanation Number Segment ID 10238 NOT USED 10239 SIMILAR ILL DT DTPO2 The qualifier indicating the format used to report the onset of FMT Q INVALID similar illness or symptom date for this claim is invalid Valid Value D8 Date expressed in format CCYYMMDD This information is not used for DMERC 10240 SIMILAR ILL DT DTPO3 The onset of similar illness or symptom date entered is INVALID FMT invalid for this claim When entered this information must be entered in a valid CCYYMMDD format This information is not used for DMERC 10241 SIMILAR ILL DT DTPO3 The onset of similar illness or symptom date entered is FUTURE DT invalid for this claim When entered this information must not be greater than today s date This infor
349. representing the number of units exceeds 15 COUNT positions EXCEEDS MAXIMUM Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 173 Edit Edit Description Element Edit Explanation Number Segment ID 10978 SVC UNIT SV104 The value representing the number of units exceeds the COUNT maximum number of positions to the right of the decimal EXCEEDS MAX point DECIMAL PLACES 10979 PT WEIGHT CR102 The value representing the patient weight for ambulance EXCEEDS certification exceeds 10 positions MAXIMUM This information is not used for DMERC 10980 PT WEIGHT CR102 The value representing the ambulance transport distance EXCEEDS MAX exceeds two positions to the right of the decimal point DECIMAL PLACES This information is not used for DMERC 10981 TRANSPORT CR106 The value representing the ambulance transport distance DIST exceeds 15 positions EXCEEDS MAXIMUM This information is not used for DMERC 10982 TRANSPORT CR106 The value representing the ambulance transport distance DIST CANNOT exceeds 1 position to the right of the decimal point HAVE gt 1 DEC PLACES This information is not used for DMERC 10983 TREATMENT CR201 The value representing the chiropractic series treatment SERIES number exceeds nine positions EXCEEDS MAXIMUM This information is not used for DMERC 10984 TREATMENT CR201 The value representing the chiropractic series treatment SERIES number
350. riber is the INFORMATION insured the patient demographic segment is required MISSING Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 25 Edit Edit Description Element Edit Explanation Number Segment ID 10122 SUBSCRIBER DMGO1 The qualifier indicating the format used to report the DOB QUAL subscriber s date of birth is invalid for this claim INVALID Valid Value D8 Date Expressed in Format CCYYMMDD 10123 SUBSCRIBER DMGO03 The qualifier used to identify the subscriber s sex is invalid SEX CODE for this claim INVALID Valid Values F Female M Male U Unknown 10124 ADD REF The segment containing additional subscriber identification SUBSCRIBER information exceeds maximum use When this information is ID SEGMENT reported only 4 occurrences per subscriber may be used EXC MAX USE This information is not used for DMERC 10125 SUBSCRIBER REFO1 The qualifier for the subscriber secondary identification ID 2 QUAL number information for this subscriber is invalid INVALID Valid Values 1W Member identification number 23 Client number IG Insurance policy number SY Social Security Number This information is not used for DMERC 10126 SUBSCRIBER REFO1 The qualifier used to indicate the primary identification ID2 number for this subscriber is duplicated as the secondary SUBSCRIBER identifier for this subscriber ID 1 Valid Values 1W Member identi
351. ril 2003 Front End Edits Page 207 Edit Edit Description Element Edit Explanation Number Segment ID 11229 DRUG CTP04 The national drug unit count amount exceeds two positions QUANTITY to the right of the decimal point INVALID DECIMAL This information is not used for DMERC FORMAT 11230 UNIT MEASUR_ CTPO5 1 The qualifier identifying the type of service units being EMENT reported is invalid for this claim line QUALIFIER INVALID Valid Values F2 International unit GR Gram ML Milliliter UN Unit This information is not used for DMERC 11231 DRUG LOOP REFO1 The qualifier indicating the type of prescription number for 2410 REF ID this claim line is invalid QUALIFIER INVALID Valid Value XZ Pharmacy Prescription Number This information is not used for DMERC 11232 REFERENCE REF02 The prescription number is missing for this claim line When IDENTIFICATIO the prescription number segment is used this is a required N MISSING element This information is not used for DMERC 11236 2410 REF REF The segment providing the prescription number for this line INVALID FOR is invalid X12 VERSION This edit indicates an invalid format and should be resolved by contacting your software vendor This information is not used for DMERC 11247 REF SEGMENT REF The segment containing prescription number information EXCEEDS exceeds maximum use When this information is reported MAXIMUM USE only 1 occurrence per l
352. ring provider secondary identification number is missing for this line This information is not used for DMERC 10859 CANNOT SEND gt 4 2420G NM1 SEGMENTS NM1 The segment providing the other payer s who issued the prior authorization or referral number name information for this line exceeds maximum use When this information is reported only 4 occurrences per subscriber may be used This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare This information is not used for DMERC 10860 ENTITY ID CODE INVALID NM101 The qualifier identifying the other payer for this transaction is invalid Valid Value PR Payer This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 157 Edit Number Edit Description Element Segment ID Edit Explanation 10861 OTHER PAY PRIOR AUTH REFER QUAL INVALID NM102 The qualifier identifying the other payer type who issued the prior authorization or referral number type is invalid for this line Valid Value 2 Non person entity This information is used for Medicare Secondary Payer claims and
353. rnity pricing 10 Other pricing 11 Lower of cost 12 Ratio of cost 13 Cost reimbursed 14 Adjustment pricing This information is not used for DMERC 10775 ALLOW AMT PRICE MISSING HCP02 The repriced allowed amount for this line is missing This information is not used for DMERC 10776 PROD SER ID QUALIFIER INVALID HCP09 The qualifier identifying the code format used by the repricer is invalid for this line Valid Values HC HCPCS IV HIEC ZZ Mutually defined This information is not used for DMERC 10777 UNIT BASIS MEAS CODE INVALID HCP 11 The qualifier identifying the measurement used by the repricer for units of service is invalid for this line Valid Values DA Days UN Units This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 142 Chapter Seven Edit Number Edit Description Element Segment ID Edit Explanation 10778 REJ REAS CODE INVALID HCP13 The qualifier identifying the reason code for rejecting this service by the repricer for is invalid for this line Valid Values T1 Cannot identify provider as TPO Third Party Organization participant T2 Cannot identify payer as TPO Third Party Organization participant T3 Cannot identify insured as TPO Third Party Organization participant T4 Payer name or identifier missing T5 Certification information missi
354. rovider number indicated on this claim for the ID INVALID rendering provider is invalid Verify the number entered is a valid supplier number as assigned by the National Supplier Clearinghouse This information is not used for DMERC 20072 PURCHASE SERV REFO1 The qualifier for the purchased service provider s PROV ID QUALIFIER secondary identification number for this claim is invalid INVALID Valid Value 1C Medicare provider number 1G Provider UPIN number This information is not used for DMERC 20073 PURCHASE SERV REF02 The secondary identification number indicated on this PROVIDER ID claim for the purchased service provider is invalid INVALID Verify the number entered is a valid supplier number as assigned by the National Supplier Clearinghouse This information is not used for DMERC 20074 SERVICE NM103 The service facility location or oxygen test facility name FACILITY LAB NAME INVALID was entered in an invalid format Verify the first position of the service facility location or oxygen test facility is an alpha character and does not contain spaces Region D DMERC EDI Manual Revised April 2003 Front End Edits Medicare Page 11 Edit Number EDIT DESCRIPTION Element ID Edit Explanation 20075 SERVICE N301 The service facility location or oxygen test facility s FACILITY LAB address listed on this claim was entered in an invalid ADDDRESS1 format Verify the first position
355. rt the date WORK FMT Q last worked for this claim is invalid INVALID Valid Value D8 Date expressed in format CCYYMMDD This information is not used for DMERC 10280 DT LAST DTP03 The date last worked entered is invalid for this claim When WORK INVALID entered this information must be entered in a CCYYMMDD FMT format This information is not used for DMERC 10281 DT LAST DTP03 The date last worked entered is invalid for this claim When WORK entered this information must not be greater than today s FUTURE DT date This information is not used for DMERC 10282 DT AUTH RET DTP The segment providing the date authorized to return to work WORK SEG for this claim exceeds maximum use If this information is EXC MAX USE reported only 1 occurrence per claim may be used This information is not used for DMERC 10283 NOT USED www cignamedicare com edi Revised April 2003 Page 48 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10284 DT AUTH RET DTP02 The qualifier indicating the format used to report the WORK FMT Q authorized to return to work date for this claim is invalid INVALID Valid Value D8 Date expressed in format CCYYMMDD This information is not used for DMERC 10285 DT AUTH RET DTPO3 The date authorized to return to work entered is invalid for WORK INVALID this claim When entered this information must be entered FMT in a CCYYMMDD format
356. ry identification number is invalid Valid values 24 Employer s identification number 34 Social Security Number XX National Provider Identifier This information is not used for DMERC 20177 REF PROV ID QUAL INVALID NM108 The qualifier used to indicate the referring provider s primary identification number is invalid Valid values 24 Employer s identification number 34 Social Security Number XX National Provider Identifier This information is not used for DMERC 20178 REND PROV ID QUAL INVALID NM108 The qualifier used to indicate the rendering provider s primary identification number is invalid Valid values 24 Employer s identification number 34 Social Security Number XX National Provider Identifier This information is not used for DMERC 20179 PURCH SERV PROV ID QUAL INVALID NM108 The qualifier used to indicate the purchased service provider s primary identification number is invalid Valid values 24 Employer s identification number 34 Social Security Number XX National Provider Identifier This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 30 Chapter Eight Edit Number EDIT DESCRIPTION Element ID Edit Explanation 20180 SERVICE FACILITY ID QUAL INVALID NM108 The qualifier used to indicate the service facility s primary identificati
357. s 37 Oxygen delivery equipment is stationary 38 Certification signed by the physician is on file at the supplier s office AL Ambulation limitations P1 Patient was discharged from the first ZV Replacement item 10639 COND CODE CRC04 The code indicating the patient s secondary condition is INVALID invalid for this line Use values 37 AL and P1 for CMN form 484 2 and 38 for all DMERC CMN s including CMN form 484 2 Valid Values 37 Oxygen delivery equipment is stationary 38 Certification signed by the physician is on file at the supplier s office AL Ambulation limitations P1 Patient was discharged from the first ZV Replacement item 10640 COND CODE CRC05 The qualifier indicating the patient s third condition is invalid INVALID for this line Use values 37 AL and P1 for CMN form 484 2 and 38 for all DMERC CMN s including CMN form 484 2 Valid Values 37 Oxygen delivery equipment is stationary 38 Certification signed by the physician is on file at the supplier s office AL Ambulation limitations P1 Patient was discharged from the first ZV Replacement item Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 125 Edit Edit Description Element Edit Explanation Number Segment ID 10641 COND CODE CRC06 The qualifier indicating the patient s fourth condition is INVALID invalid for this line Use values
358. s etc MCM 3023 4 The following are the steps necessary for completing the testing process 1 Send a minimumof 25 claims contained in one batch into the test facility Re fer to Chapter 5 of this manual for instructions on transmitting your claims into the test facility MCM 3023 4 We encourage you to test a variety of claims representative of the actual claims you will be transmitting in production Any claims you send during testing will not be processed for payment Within 1 2 hours of transmitting your claims your test results will be available to download The results will appear on the 997 report and will be available to download directly from your Stratus mailbox The 997 report will indicate an Accepted or Rejected message If you receive an Accepted this is an indication that there was a 100 error free acceptance rate and your test claims will automatically move to Phase II of the testing process Go to Step 3 If you receive a Rejected this is an indication that there were errors detected If you receive errors in Phase I you must correct the errors and retransmit your claims Go back to Step 1 See Example 1 of the 997 report section in Chapter 6 of this manual Note You must pass the ANSI X12N file validation in Phase I of the testing process in order for your claims to move to Phase II of the testing process If you don t download the 997 report for Phase I and there are errors CIGNA Medicare will
359. s another payer adjudicated this claim prior to being submitted to Medicare This information is used for Medigap secondary to Medicare claims and should not be submitted unless there is an approved Medigap policy held by this subscriber 10507 OTH SUB N2 The segment providing additional other payer s subscriber NAME INFO name information for this claim exceeds maximum use EXC MAX USE When this information is reported only 1 occurrence per transaction may be used This information is not used for DMERC 10508 OTH SUB N3 The segment providing the other payer insured s address for ADDRESS EXC this claim exceeds maximum use When this information is MAX US reported only 1 occurrence per transaction may be used This information is not used by DMERC 10509 OTH INS N402 The other payer s insured state abbreviation is missing for STATE CODE this claim When reporting address information the city INVALID state and zip code information must be included This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 94 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10510 REF ID REFO1 The qualifier for the other insured secondary Identification QUALIFIER number information for this c
360. s field will show the DMERC this claim was transferred to on accepted claims or the DMERC the claim should have transferred to on Rejected claims Level of rejection For rejected claims the rejection level will be reported here Please see introduction of this chapter for further explanation on the levels of editing Page 20 Chapter Six Report 716004 Submission Summary The Submission Summary report is included with every Electronic Report Package and is an excellent tool for balancing your claim totals This report summarizes the number and dollar amounts of assigned and or non assigned claims received accepted rejected and transferred by Region D DMERC for each transaction transmitted for a particular run date The information contained in this report includes Assigned claims information The total number of assigned claims received accepted rejected and transferred by Region DDMERC The percentage of assigned claims that were accepted rejected and transferred in relation to the total number of assigned claims received The total dollar amount of assigned claims received accepted rejected and transferred The percentage in dollar amount of assigned claims accepted rejected transferred as that dollar amo unt relates to the dollar amount of received assigned claims Non assigned claims information The total number of non assigned claims received accepted rejected and transferred by Region DDMERC The percentage
361. s information is not used for DMERC MAXIMUM www cignamedicare com edi Revised April 2003 Front End Edits Page 176 Edit Edit Description Element Edit Explanation Number Segment ID 11000 ANESTH QTY02 The value entered as the anesthesia modifying units MODIFYING exceeds the maximum number of positions to the right of the UNITS decimal point EXCEEDS MAX DEC This information is not used for DMERC 11001 TEST RESULT MEA03 The test result entered for the ABG or oxygen saturation test VALUE as reported on the oxygen certification form 484 2 or the EXCEEDS subscriber s height as reported on DMERC CMNs exceeds MAXIMUM 20 positions 11002 TEST RESULT MEA03 The test result entered for the ABG or oxygen saturation test VALUE as reported on the oxygen certification form 484 2 or the EXCEEDS MAX subscriber s height as reported on DMERC CMNs exceeds DEC the maximum positions to the right of the decimal point 11003 CONTRACT CN102 The contract amount information at the service line is AMT EXCEEDS invalid this amount cannot exceed 18 positions MAXIMUM This information is not used for DMERC 11004 CONTRACT CN103 The contract amount Information at the service line is AMT CANNOT invalid This amount cannot exceed two positions to the right HAVE gt 2 DEC of the decimal point PLACES This information is not used by DMERC 11005 TERMS DISC CN105 The contract terms discount percent informatio
362. s invalid This element requires one of CODE INVALID the following values be used CIGNA DMERC will acknowledge every interchange received regardless of the value submitted Valid Values 0 No acknowledgement requested 1 Interchange acknowledgement requested 10013 INTEST PROD ISA15 The test production indicator for this interchange is invalid IND INVALID You must enter the correct usage indicator in this element Valid Values P Production indicator T Test data 10014 FG TYPE GS01 The qualifier identifying the type of functional group being CODE INVALID submitted is invalid Valid Value HC Health Care Claim 837 This edit indicates an invalid format and should be resolved by contacting your software vendor www cignamedicare com edi Revised April 2003 Page 8 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10015 FG CREATE GS04 The creation date entered is invalid for this functional group DATE INVALID This information must be entered ina CCYYMMDD format FORMAT This edit indicates an invalid format and should be resolved by contacting your software vendor 10016 FG CREATE GS04 The creation date entered is invalid for this functional group DATE FUTURE This information must not be greater than today s date DATE This edit indicates an invalid format and should be resolved by contacting your software vendor 10017 FG CREATE GS05 The creation time
363. s not used for DMERC 10344 NOT USED 10345 APG NBR REF02 The ambulatory patient group number is missing for this MISSING claim This information is not used for DMERC 10346 MEDICAL REF The segment containing the medical record number RCRD NBR information exceeds maximum use When this information is SEG EXC MAX reported only 1 occurrence per claim may be used USE This information is not used for DMERC 10347 NOT USED 10348 MEDICAL REF02 The medical record number is missing for this claim RCRD NBR MISSING This information is not used for DMERC 10349 DEMO PROJ ID REF The segment containing the demonstration project identifier SEGMENT EXC information exceeds maximum use When this information is MAX USE reported only 1 occurrence per claim may be used This information is not used for Region D DMERC 10350 NOT USED www cignamedicare com edi Revised April 2003 Page 56 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10351 DEMO PROJ ID REF02 The demonstration project identification code is missing MISSING from this claim This information is not used for Region D DMERC 10352 NARRATIVE NTE The segment providing additional narrative information for SEGMENT EXC this claim exceeds maximum use When this information is MAX USE reported only 1 occurrence per claim may be used 10353 NARRATIVE NTE01 The qualifier identifying the type of additional narrative TY
364. s of face to face meetings or Webinars which are interactive web based training sessions www cignamedicare com wrkshp dm SEMINARS WEBINARS In addition to our on site seminars Region D DMERC also provides Webinars web based seminars for more convenient access to Medicare education http www cignamedicare com wrkshp dm index html REGION D DMERC SUPPLIER MANUAL http www dgnamedicare com dmerddmsm index html toc REGION D DMERC DIALOGUE The DMERC Dialogue is a service of CIGNA HealthCare Medicare Administration Together with occasional special releases the DMERC Dialogue serves as legal notice to suppliers concerning responsibilities and requirements imposed upon them by Medicare law regulations and guidelines htto www cignamedicare com dmerd dlog index as DMERC VENDOR GAZETTE The Vendor Gazette has been developed especially for software vendors The Vendor Gazette together with occasional special releases serves as legal notice to vendors concerning the responsibilities and requirements imposed upon them by Medicare law regulations and guidelines http www dgnamedicare com edi gazette index htm DMERC EDI EDGE The purpose of the EDI Edge is to provide you with the information which will allow you to take full advantage of all the benefits of electronic billing Additionally the EDI Edge contains vital information that will help you avoid common billing pitfalls which may delay payment htto www dgnam
365. s transported for the care of a specialist or for availability of specialized equipment E Patient transferred to rehabilitation facility This information is not used for DMERC 10357 AMBO DIST CR105 The unit of measurement to indicate the distance the MEA QUAL ambulance traveled for this claim is invalid INVALID Valid Value DH Miles This information is not used for DMERC 10358 AMBO RND CR109 This element is used to provide narrative information to TRIP NAR indicate the purpose of the round trip ambulance service for MISSING this claim This is a required element if the ambulance transport was a round trip This information is not used for DMERC 10359 NUMBER OF CR201 The value representing the number of chiropractic service CHIRO SVC treatments in the series is missing from this claim MISSING This information is not used for DMERC 10360 NBR OF CHIRO CR202 The value representing the total number of treatments TREATMNT ordered in this series is missing from this claim MISSING This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 58 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10361 LVL OF CHIRO CR203 The qualifier indicating the level of subluxation on SUBLX CODE 1 chiropractic services is invalid for this claim For claims INVALID involving subluxation this information is required Valid Values C1 Cervical 1
366. s used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10937 ADJ AMOUNT CAS12 The value representing the claim level adjusted amount EXCEEDS exceeds 18 positions MAXIMUM This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10938 ADJ AMOUNT CAS12 The value representing the claim level adjustment amount CANNOT HAVE exceeds two positions to the right of the decimal point gt 2 DEC PLACES This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10939 ADJUSTED CAS13 The value representing the claim level adjusted units of UNITS service exceeds 15 positions EXCEEDS MAXIMUM This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10940 ADJ UNITS CAS13 The value representing the Claim level adjusted units of EXCEEDS MAX service exceeds the maximum number of positions to the DECIMAL right of the decimal point PLACES This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10941 ADJ AMOUNT CAS15 The value r
367. sed in format CCYYMMDD This information is not used for DMERC 10679 LAST SEEN DTPO3 The date last seen entered is invalid for this line When DATE INVALID entered this information must be entered in a CCYYMMDD format This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 129 Edit Edit Description Element Edit Explanation Number Segment ID 10680 LAST SEEN DTPO3 The date last seen entered is invalid for this line When DATE FUTURE entered this information must not be greater than today s DATE date This information is not used for DMERC 10681 TEST DT EXC DTP The segment providing the hemoglobin hematocrit test date MAX USE for this line exceeds maximum use When this information is reported only 2 occurrences per line may be used This information is not used for DMERC 10682 NOT USED 10683 DTE TIME PER DTP02 The qualifier indicating the format used to report the FORMAT hemoglobin hematocrit test date for this line is invalid QUALIFIER INVALID Valid Value D8 Date expressed in format CCYYMMDD This information is not used for DMERC 10684 TEST DATE DTP0O3 The hemoglobin hematocrit test date entered is invalid for INVALID this line When entered this information must be entered in a CCYYMMDD format This information is not used for DMERC 10685 TEST DATE DTPO3 The hemoglobin hematocrit test date entered is invalid for
368. sentative of products you or your customer may potentially bill The test claims must be submitted as a single batch To qualify to be included on the Certified Vendor List you must receive a 100 errorfree test There are no exceptions made if your company www cignamedicare con edi Page 2 Chapter Four would like to be included on the list If your company does not want to be included on the Certified Vendor List then refer to the requirements for supplier above 5 Once you have successfully passed Phase II of the testing process your results will then be turned over to the EDI Customer Service Department for processing Note Please allow 10 21 business days for processing Before we can activate your submitter ID and supplier numbers in our claims processing system we must have an EDI Enrollment Form and DMERC EDI Customer Profile on file Once we have activated your submitter ID you will receive a telephone call from the EDI Department informing you that your company is set up to bill electronically and that you may begin transmitting production claims to CIGNA Medicare for payment Refer to Chapters 5 and 6 of this manual for instructions on transmitting live claims and downloading 997 reports MCM 3023 4 Note When in production it is imperative you continue to download your 997 reports and error reports as CIGNA Medicare will not provide the comp limentary phone calls that we provide during in the testing process If you have questi
369. special program under which INVALID the services rendered to the patient were performed is invalid for this claim Valid values 01 Early amp Periodic Screening Diagnosis and Treatment or Child Health Assessment Program 02 Physically Handicapped Children s Program This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 32 Chapter Eight Edit Number EDIT DESCRIPTION Element ID Edit Explanation 20191 PROD SER ID QUALIFIER INVALID SVD03 1 The code used to indicate the type of procedure code being reported in the line adjudication segment for this claim line is invalid Valid value HC Health Care Financing Administration Common Procedural Coding System HCPCS Codes This information is not used for DMERC 20192 PROD SER ID QUALIFIER INVALID V101 2 The code indicating the type of procedure code entered for this line is invalid Valid values HC Health Care Financing Administration common Procedural Coding System ZZ Mutually Defined Region D DMERC EDI Manual Revised April 2003 Chapter Nine Front End Edits DMERC Introduction Front end edits are broken down into three categories or levels It is important to understand the differences between these levels to determine error resolution In addition to Medicare specific and DMERC specific edits CMS has required us to add Im
370. spinal manipulation treatment NUMBER series number for this claim line is missing MISSING This information is not used for DMERC 10607 SUBLUX LVEL CR203 The qualifier indicating the level of subluxation on CODE INVALID chiropractic services is invalid for this line For lines involving subluxation this information is required Valid Values C1 Cervical 1 C2 Cervical 2 C3 Cervical 3 C4 Cervical 4 C5 Cervical 5 C6 Cervical 6 C7 Cervical 7 CO Coccyx IL Ilium L1 Lumbar 1 L2 Lumbar 2 L3 Lumbar 3 L4 Lumbar 4 L5 Lumbar 5 OC Occiput SA Sacrum T1 Thoracic 1 T10 Thoracic 10 T11 Thoracic 11 T12 Thoracic 12 T2 Thoracic 2 T3 Thoracic 3 T4 Thoracic 4 T5 Thoracic 5 T6 Thoracic 6 T7 Thoracic 7 T8 Thoracic 8 T9 Thoracic 9 Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 117 Edit Edit Description Element Edit Explanation Number Segment ID This information is not used for DMERC 10608 SUBLUX CR204 The qualifier indicating the level of subluxation on LEVEL CODE chiropractic services is invalid for this line For lines INVALID involving subluxation this information is required to indicate a range Valid Values C1 Cervical 1 C2 Cervical 2 C3 Cervical 3 C4 Cervical 4 C5 Cervical 5 C6 Cervical 6 C7 Cervical 7 CO Coccyx IL Ilium L1 Lumbar 1 L2 Lumbar 2 L3 Lumbar 3
371. ss another payer adjudicated this claim prior to being submitted to Medicare This information is used for Medigap secondary to Medicare claims and should not be submitted unless there is an approved Medigap policy held by this subscriber Valid Values A Appropriate release of information on file at health care service provider or at utilization review organization Informed consent to release medical information for conditions or diagnoses regulated by federal statutes M The provider has limited or restricted ability to release data related to a claim N No provider is not allowed to release data O On file at payer or at plan sponsor Y Yes provider has a signed statement permitting release of medical billing data related to a claim 10501 OTH SUB NAME EXC MAX USE NM1 The segment providing the other payer s subscriber name information for this claim exceeds maximum use When this information is reported only 1 occurrence per claim may be used This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare This information is used for Medigap secondary to Medicare claims and should not be submitted unless there is an approved Medigap policy held by this subscriber 10502 ENTITY ID CODE INVALID NM101 The qualifier identifying the other payer s subscriber Referring Prov
372. sults when tested on 4 LPM for DMERC Form 484 2 GRA Gas test rate HT Height Used to report the patient s height on all DMERC CMN s requiring patient s height to be reported R1 Hemoglobin R2 Hematocrit R3 Epoetin starting dosage R4 Creatin ZO Oxygen used to report the oxygen saturation test results when tested on 4 LPM for DMERC Form 484 2 10725 TEAST MEA03 The test results or patient height being reported for this line RESULTS is missing This information is required to be sent for CMN MISSING form 484 2 and all DMERC CMN s requiring patients height 10726 CONTRACT CN101 The qualifier indicating the type of contract for encounter TYPE INVALID claims is invalid for this line Valid Values 02 Per diem 03 Variable per diem 04 Flat 05 Capitated 06 Percent 09 Other This information is not used for DMERC 10727 REPRICED LN REF The segment containing the repriced line item reference ITEM REF NUM number information exceeds maximum use When this EXC MAX USE information is reported only 1 occurrence per line may be used This information is not used for DMERC 10728 NOT USED 10729 REPRICE LINE REFO2 The repriced line item reference number is missing for this REF line MISSING This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 136 Chapter Seven Edit Edit Description Element Edit Explanation N
373. t CAIS E g amp 8 E a 8 a S a o O u Z 6 amp 7 Z O Z Z oa O i Z wi CENTERS for MENCARI amp MREDNCASD SURWRCES Z amp O O Q A A els oe eee ee S a z S CLAIM STATUS OUTSTANDING CHECKS ANNUAL DEDUCTIBLE ELIGIBILITY STATUS REES CHEDUIE ORDER PAYMENT REPORTS ORDER PUBLICATIONS UPDATED PUBLICATIONS e LEGISLATION ISSUES SEMINARS WEBINARS REVIEW REQUEST FORMS APPEAL RIGHTS FREQUENTLY ASKED QUESTIONS PHYSICIAN INFORMATION PACKET ELECTRONIC FUNDS TRANSFER DMERC FORMS REGION D SUPPLIER MANUAL LOCAL MEDICAL REVIEW POLICIES REGION D DMERC DIALOGUES UPIN DIRECTORY HELPFUL RESOURCES TO EXTERNAL ENTITIES HIPAA j REGION D DMERC CONTACTS DMERC N N N SEE BACK OF SHEET FOR DETAILED DESCRIPTIONS OF RESOURCES WHAT IS WHAT amp WHERE TO GO CIGNA MEDICARE WEB SITE DMERC http www dgnamedicare com dmerc ListSERV EXPRESS E MAIL NOTIFICATION SYSTEM By joining the CIGNA Medicare electronic mailing list you can get immediate updates on DMERC Dialogues Supplier Manuals Workshops Medical Review and other information http www cignamedicare com mailer subscribe as CMS WEB SITE http www cms hhs gov PET The Provider Education and Training department located in Boise Idaho provides education to Durable Medical Equipment suppliers by mean
374. t previously a current CMN may already be on file in our system Review CMNs before transmitting with any claims CMNs should only be transmitted when needed and not with every claim Following are some questions to consider before transmitting claims e Is the correct type of CMN being transmitted according to the documentation requirements in the various policies initial revision or recertification e Are all the sections of the CMN completed e Is the correct CMN being sent with the first claim that will be affected e Does the date on the CMN you are transmitting overlap that of a CMN already transmitted to CIGNA The following are definitions of the CMN reject error codes what causes that rejection and possible resolutions to these situations In order to obtain information regarding CMNs on file and the dates listed CIGNA Medicare suggests contacting the beneficiary the ordering physician and or the previous supplier A final option is to have the beneficiary utilize the toll free line 800 899 7095 to inquire about previous services CIGNA Medicare is unable to release specific information to a supplier until they have filed a claim Once a claim has been received for the item indicated on the CMN reject report the supplier may contact the CIGNA Medicare Public Relations Department toll free at 866 224 3094 option 3 If the claim has been denied with ANSI code M3 Equipment is the same or similar to equipment already being used
375. t segment S35 security start segment missing for S3E security end segment S4E security end segment missing for S4S security start segment S4S security start segment missing for S4E security end segment www cignamedicare com edi Page 26 Chapter Six Segment and Element Function Group Acknowledg ement Code Number of Transaction Sets ST SE Included Number of Received Transaction Sets Number of Accepted Transaction Sets Element Description Code acknowledging the functional group GS GE identified in the AK102 Total number of transaction sets included in this functional group GS GE This is identical to the GEO1on the originally received transaction Actual number of transaction sets received Total number of transaction sets accepted out of the number in AK902 Region D DMERC EDI Manual November 2001 Valid Values with Description Accepted functional group was accepted and passed on to VMS for editing Accepted but errors were noted Rejected Message Authentication Code MAC failed Rejected functional group was rejected errors noted in AK3 and or AK4 need corrected and transaction needs to be resubmitted Rejected assurance failed validity test Rejected content after decryption could not be analyzed Page 12 Chapter Six Segment and Element Element Name Element Description Functional Code indicating error in Group functional group Syntax Code 10
376. t the EDI Department 10050 HL TYPE QUAL HLO3 The code identifying this hierarchical level is invalid INVALID Valid Value 20 Information source This edit indicates an invalid format and should be resolved by contacting your software vendor 10051 HL CHILD HLO4 The hierarchical child code is invalid CODE INVALID Valid Value 1 Additional subordinate HL data segment in this hierarchical structure This edit indicates an invalid format and should be resolved by contacting your software vendor 10053 BILL PAYTO PRVO1 The qualifier identifying the type of provider being reported PROV QUAL for this transaction is invalid INVALID Valid Values BI Billing PT Pay to 10054 BILL PAYTO PRV02 The qualifier identifying the type of identification number PROV ENTITY being reported for the billing provider is invalid for this TYPE QUAL transaction INVALID Valid Value ZZ Mutually Defined Health Care Provider Taxonomy Code List 10055 FORIEGN CUR The segment containing foreign currency information is not CURRENCY a valid segment for Medicare claims and should not be sent SEGMENT USED 10056 BILL PROV NM1 The segment providing name information for the billing NAME provider of this transaction is missing SEGMENT MISSING This information is required on all DMERC transactions www cignamedicare com edi Revised April 2003 Page 14 Chapter Seven Edit Edit Description Element Edit Ex
377. t used for DMERC 10824 SPV PROV REF02 The supervising provider s secondary identification number UPIN MISSING is missing for this line This information is not used for DMERC 10825 CANNOT SEND NM1 The segment providing the ordering provider name gt 1 ORD PROV information for this line exceeds maximum use When this NAME information is reported only 1 occurrence per line may be SEGMENT used Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 151 Edit Edit Description Element Edit Explanation Number Segment ID 10826 ORD PROV ID NM101 The qualifier identifying the ordering physician for this line is CODE INVALID invalid Valid Value DK Ordering physician 10827 ORD PROV NM102 The qualifier identifying the ordering physician type is invalid QUALIFIER for this line INVALID Valid Value 1 Person 10828 ORD PROV NM103 The last name or company name is missing for this line If LAST NAME you have specified the ordering physician type to be a MISSING person this element must contain the last name of that person If the ordering physician was identified as a non person entity this element must contain the company name 10829 ORD PROV NM104 The first name of the ordering physician is missing for this FIRST NAME line If you have specified the ordering physician type to be a MISSING person this element must contain the first name of that person 10830 ORD PROV ID NM108 The
378. t used to report the hearing DT FMT Q and vision prescription date for this claim is invalid INVALID Valid Value D8 Date expressed in format CCYYMMDD This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 46 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10266 HEAR VIS RX DTPO3 The hearing and vision prescription date entered is invalid DT INVALID for this claim When entered this information must be FMT entered in a CCYYMMDD format This information is not used for DMERC 10267 HEAR VIS RX DTPO3 The hearing and vision prescription date entered is invalid DT FUTURE DT for this claim When entered this information must not be greater than today s date This information is not used for DMERC 10268 DIS BEGIN DT DTP The segment providing the disability begin date for this claim SEG EXC MAX exceeds maximum use If this information is reported only 5 USE occurrences per claim may be used This information is not used for DMERC 10269 NOT USED 10270 DIS BEGIN DT DTP02 The qualifier indicating the format used to report the FMT Q INVALID disability from date for this claim is invalid Valid Value D8 Date expressed in format CCYYMMDD This information is not used for DMERC 10271 DIS BEGIN DT DTPO3 The disability from date entered is invalid for this claim INVALID FMT When entered this information must be en
379. tain the last name of that MISSING person If the submitter was identified as a non person entity this element must contain the company name 10034 SUBMITTER NM104 The first name of the submitter is missing for this FIRST NAME transaction If you have specified the submitter type to be a MISSING person this element must contain the first name of that person If the submitter was identified as a non person entity this element is not used Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 11 Edit Edit Description Element Edit Explanation Number Segment ID 10035 SUBMITTER ID NM108 The qualifier identifying the submitter identification number NUMBER for this transaction is invalid QUAL INVALID Valid Value 46 Submitter 10036 SUBMITTER N2 The segment providing additional name information for the ADD NAME submitter for this transaction exceeds maximum use When SEGMENT EXC this information is reported only 1 occurrence per MAX USE transaction may be used This information is not used for DMERC 10037 SUBMITTER PER The segment providing contact information for the submitter CONTACT of this transaction is missing This information is required on INFO all DMERC transactions SEGMENT MISSING 10038 SUBMITTER PERO1 The qualifier for the submitter contact information for this CONTACT transaction is invalid for this transaction QUAL INVALID Valid Value IC Information co
380. tarted information technical requirements and contact information a link to the EDI Edge vendor lists and most importantly the EDI forms and applications EDI Edge This is the quarterly newsletter that serves as an information source for electronic billers This newsletter is available exclusively via the CIGNA Medicare Web site It contains information on new updates to the EDI Department tips on fixing front end rejections frequently asked questions and other articles to assist electronic billers Electronic Mailing List Sign up for our electronic mailing list and receive the latest on EDI automatically In addition to being notified of the most up to date news on Medicare you will also be notified when there is a new issue of the EDI Edge available on the Web site To sign up for the list go to www cignamedicare com There is no charge for this membership Additional EDI products and services Once you are enrolled and an active electronic biller there are several additional EDI products and services available to improve your productivity and to allow for more claim control Below is a brief overview of each of the options Refer to Chapter 2 of this manual for more details and specific requirements on EDI products and services Electronic Remittance Notices ERNs ERNs are electronic reports of claim payment and or denial information from CIGNA Medicare This information when used in conjunction with the necessary ERN reader soft
381. ted on the rejected CMN Type The type of CMN submitted with the claim INIT Initial RECER Recertification REVIS Revised Recert revised date This date is the recertification or revision date submitted on the rejected CMN Form This is the CMN form number Error Codes The error code explains why the CMN was rejected A brief description is provided next to the error code Total CMNs Rejected This number indicates the total number of CMNs rejected per submitter This report will print only once per submitter per run date Region D DMERC EDI Manual November 2001 Electronic Reports Page 25 The Certificate of Medical Necessity CMN reject report appears at the end of the Electronic Report Package and lists claims with rejected CMNs Rejected CMNs have a four digit reject code The rejection codes and explanations can be found in Chapter 6 of this manual It is possible a claim will be accepted into our processing system but the CMN may still be rejected Many CMNs are rejected simply because they are not completed properly Here are some tips to help ensure your CMNs are completed correctly In addition these simple guidelines will help prevent ANSI Code B17 claim denials All CMN rejections occur when another CMN is on file in our system for the same procedure code and beneficiary Remember that duplicate CMNs will be rejected In addition if another supplier has provided same or similar equipmen
382. ter i pOO0000027 fed4 BO00000027 fed4 6 An informational screen will appear showing the status of the file transfer This box will disappear when the transfer is complete or aborted When your transmission is complete you will receive the message Transfer Complete Enter PROTOCOL selection X for XMODEM Y for YMODEM 1 for 1K XMODEM K for KERMIT 2_ for _7MONRM nr N n OUTM gt z Zmodem file send for stratus Receiving FILENAD Sending PAWPDOCS ansi Stratus Test Cases 1004 snf tat Scigna ml d02 gt FXE i Last event Sending Files 1 of 1 Place your I Status Sending Retries fo set options 32 File ox of 1K Press lt RETURN gt ai Kn B000000027feq4 Flepsed Remaining Throughput 5000000027fed4 5000000027fed4 B000000027 fed4 J gps bps B000000027 fed4 B000000027 fed4 B000000027 fed4 B000000027 fed4 Note Please consult your claims development software for filename and location of your ANSI 4010 837 transaction www cignamedicare con edi Revised June 2002 Page 16 Chapter Five Press Enter after the transfer is complete to return to the Mailbox Access Facility menu If Enter is pressed prior to completion of the file transmission the transmission will be aborted Function Selected Put a file in your mailbox UPLOAD Enter PROTOCOL selection X for XMODEM Y for YMODEM 1 for 1K XMODEM K for KERMIT Z for ZMODEM or Q t
383. tered in a CCYYMMDD format This information is not used for DMERC 10272 DIS BEGIN DT DTPO3 The disability from date entered is invalid for this claim FUTURE DT When entered this information must not be greater than today s date This information is not used for DMERC 10273 DIS END DT DTP The segment providing the disability end date for this claim SEG EXC MAX exceeds maximum use If this information is reported only 5 USE occurrences per claim may be used This information is not used for DMERC 10274 NOT USED Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 47 Edit Edit Description Element Edit Explanation Number Segment ID 10275 DIS END DT DTP02 The qualifier indicating the format used to report the FMT Q INVALID disability end date for this claim is invalid Valid Value D8 Date expressed in format CCYYMMDD This information is not used for DMERC 10276 DIS END DT DTP03 The disability end date entered is invalid for this claim INVALID FMT When entered this information must be entered in a CCYYMMDD format This information is not used for DMERC 10277 DT LAST DTP The segment providing the date last worked for this claim WORK SEG exceeds maximum use If this information is reported only 1 EXC MAX USE occurrence per claim may be used This information is not used for DMERC 10278 NOT USED 10279 DT LAST DTP02 The qualifier indicating the format used to repo
384. th more complex inquiries to speak directly to an agent The existing toll free line 877 320 0390 will be devoted to inquiries that can be conducted entirely through the Interactive Voice Response Unit IVR Complex inquiries that cannot be resolved through the IVR can be made to the new toll free number 866 243 7272 where Customer Service Agents will be available to assist you When will this new plan go into effect noticed Palmetto GBA Region C is implementing the same plan in March 2003 CIGNA Medicare will go live with the new toll free line in April 14 2003 When should call the IVR line versus the customer service line The customer service line is reserved for complex issues that cannot be resolved by using the IVR Inquiries that must be made to the IVR line include Claim Status pending denied paid and or applied to deductible Outstanding Check Information Current Deductible Information available to participating suppliers Medicare Beneficiary Eligibility Information Allowable Information Duplicate Payment Reports Ordering Publications New Legislation Supplier Issues and Educational Seminar Information Information About Appeal Rights If contact a Customer Service Agent with an issue that can be handled through the IVR will they still be able to assist me Suppliers contacting the Customer Service Agents with inquiries that can be handled through the IVR will be advised to disconnect and call the IVR to
385. the X12N 837 Professional implementation guide Additional companion documents trading partner agreements will be developed for use with other HIPAA standards as they become available e Negative values submitted in the following fields will not be processed and will result in the claim being rejected Total Claim Charge Amount 2300 Loop CLM02 Patient Amount Paid 2300 Loop AMT02 Patient Weight 2300 and 2400 Loop CR102 Transport Distance 2300 and 2400 Loop CR106 Payer Paid Amount 2320 Loop AMT02 Allowed Amount 2320 Loop AMT02 Line Item Charge Amount 2400 Loop SV102 Service Unit Count 2400 Loop SV104 Total Purchased Service Amount 2300 Loop AMTO2 and Purchased Service Charge Amount 2400 Loop PS102 e The only valid values for CLM05 3 Claim Frequency Type Code are 1 ORIGINAL and 7 REPLACEMENT Claims with a value of 7 will be processed as original claims and will result in duplicate claim rejection The claims processing system does not process electronic replacements e The maximum number of characters to be submitted in the dollar amount field is seven characters Claims in excess of 99 999 99 will be rejected e Claims that contain percentage amounts submitted with values in excess of 99 99 will be rejected e Claims that contain percentage amounts submitted with more than two positions to the left or the right of the decimal will be rejected e Data submitted in CLM20 Delay Reason Code will
386. thin the transaction where the error occurred This segment will not be present on the 997 report if an Accepted A status code is reported This status code can be found in AK901 This segment reports errors with data elements within the segment identified in AK3 This segment will provide the element information including position in the segment and a copy of the data included within this element This segment will not be present on the 997 report if an Accepted A status code is reported This status code can be found in AK901 This segment indicates the result of the transaction set originally submitted The most common values are A for Accepted and R for Rejected when used If an R appears in the AK5 segment you must correct the errors noted in AK3 and AK4 and resubmit the transaction This segment indicates the result of the Functional Group originally submitted The most common values A for Accepted and R for Rejected If an R appears in the AK9 segment you must correct the errors noted in AK3 and AK4 and resubmit the transaction www cignamedicare con edi Page 6 Chapter Six Each segment can be broken down by element Below is a list of the elements for each segment For example AK101 is Segment AK1 Element 01 Along with the element edit number is the element name description and valid values If you encounter these edits it may indicate a data entry error or formatting issues with your billi
387. this claim is invalid Verify the correct code was entered off of the primary payer s electronic remittance advice This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 20097 REMARK CODE 5 INVALID MOA07 The remark code indicated on this claim is invalid Verify the correct code was entered off of the primary payer s electronic remittance advice This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 20098 SUBSCRIBER LNAME OR ORG NAME INVALID NM103 The other insured s last name was entered in an invalid format Verify the first position of the insured s last name is an alpha character and does not contain spaces Make sure the first three positions of the other insured s last name are not any of the following MR MR DR DR JR or JR This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare This information is used for Medigap secondary to Medicare claims and should not be submitted unless there is an approved Medigap policy held by this subscriber Region D DMERC EDI Manual Revised April 2003 Front End Edits Medicare Page 15
388. this transaction is missing Valid Value 1C Medicare provider number 20010 BILLING PROVIDER REF02 The secondary identification number indicated in this SECONDARY ID transaction for the billing provider is invalid Verify the INVALID number entered is a valid supplier number as assigned by the National Supplier Clearinghouse 20011 BILLING PROVIDER REF02 The supplier number indicated in this transaction for the SECONDARY ID billing provider is not currently authorized to bill INVALID electronically and or we do not have an EDI Enrollment form on file 20012 PAY TO PROVIDER N402 The state abbreviation indicated in this transaction for STATE CODE the pay to provider state is not a valid two character INVALID state abbreviation code This information is not used for DMERC 20013 PAY TO PROVIDER N403 The zip code indicated in this transaction for pay to ZIP CODE INVALID provider address was reported in an invalid format Verify the zip code contains only numeric data and is not all zeros or all nines and is either five or nine digits in length This information is not used for DMERC 20014 PAY TO PROVIDER N404 The country code indicated in this transaction for the COUNTRY CODE pay to provider s address is not a valid country code INVALID This information is not used for DMERC 20015 PAY TO PROV ID REFO1 The qualifier for the pay to provider s secondary CODE QUALIFIER identification number information for this transaction is INVALID inva
389. tient when other than the SEGMENT EXC subscriber address for this claim exceeds maximum use MAX USE When this information is reported only 1 occurrence per transaction may be used This information is not used for DMERC 10175 PAT C S Z N4 The segment providing city state and zip code information SEGMENT for the patient when other than the subscriber for this claim MISSING is missing When reporting address information the city state and zip code information must be included This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 33 Edit Edit Description Element Edit Explanation Number Segment ID 10176 PAT CITY N401 The patient s when other than the subscriber city is missing MISSING for this claim When reporting address information the city state and zip code information must be included This information is not used for DMERC 10177 PAT STATE N402 The patient s when other than the subscriber state ABR MISSING abbreviation is missing for this claim When reporting address information the city state and zip code information must be included This information is not used for DMERC 10178 PAT ZIP CODE N403 The patient s when other than subscriber zip code is MISSING missing for this claim When reporting address information the city state and zip code information must be included This information is not use
390. tions MAXIMUM This information is not used for DMERC 10924 MODULUS HSD04 The value representing the health care services delivery AMT EXCEEDS sampling frequency exceeds the maximum number of MAX DECIMAL positions to the right of the decimal point PLACES This information is not used for DMERC 10925 ADJ AMOUNT CAS03 The value representing the claim level total adjustment EXCEEDS amount exceeds 18 positions MAXIMUM This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10926 ADJ AMOUNT CAS03 The value representing the claim level total adjustment CANNOT HAVE amount exceeds two positions to the right of the decimal gt 2 DEC point PLACES This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 10927 ADJUSTED CAS04 The value representing the claim level total adjusted units of UNITS service exceeds 15 positions EXCEEDS MAXIMUM This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare www cignamedicare com edi Revised April 2003 Page 166 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 10928 ADJ UNITS CAS04 The value
391. tronic Report Package The reports are referenced by report number The report numbers are located in the upper left hand corner of each page of the reports CARRIER 05655 PROGRAM X8371600 REPORT 716001 The reports included in the Electronic Report Package are e Report 716001 Submitter Reports Cover Page e Report 716002 Received Claims Listing e Report 716004 Submission Summary e Report 716003 Error Listing e Report 716006 CMN Reject Listing Reports 716001 716002 and 716004 will be included in every Electronic Report Package Reports 716003 and 716006 will only be included if there are errors in the claim or CMN file The next few pages provide a description and example of each report included in the Electronic Report Package Instructions for downloading the package may be found in Chapter 5 www cignamedicare com edi Page 26 Chapter Six Report 716001 Submitter Reports Cover Page This report is included with every Electronic Report Package The Submitter Reports Cover Page indicates the following information e The date the file was received by CIGNA Medicare e The date and time the file was transmitted e The Submitter ID and contact person e The submitter name and address This information is derived from CIGNA Medicare s submitter records e The Interchange Sender ID as included in the ANSI X123N 837 transaction e The Claim Control Number CCN assigned by the submitter of the ANSI X123N 837 transacti
392. tted on the incoming 837 transaction The company name and address information comes from DMERC submitter records Time report was generated by claim processing system Electronic Reports Page 17 Report 716002 Received Claims Listing The Received Claims Listing report is included with every Electronic Report Package and will follow the Submitter Reports Cover Page Report 716001 This report will provide Claim Control Numbers CCNs assigned by CIGNA Medicare to claims that were accepted into the claims processing system If there is not a CCN assigned to an individual claim this is an indication that the claim either contains errors or it was transferred to another DMERC This report will be organized by the billing provider s supplier number This is beneficial for billing services or large companies that bill using multiple supplier numbers in a single transaction Rather than locating a particular supplier s claims among the total claims transmitted a separate Received Claims Listing report will be generated for each supplier The information contained on the Received Claims Listing report includes e The subscriber s HICN Medicare number e The name of the beneficiary e The patient account number e The date of service e The Claim Control Number CCN IfaCCN is not assigned the claim may have been rejected on the front end due to data errors or transferred to another region for processing To determine the cause
393. ue 1C Medicare provider number 20082 SERVICE REF02 The provider number indicated on this claim for the FACILITY LAB ID service facility location or oxygen test facility is invalid INVALID Verify the number entered is a valid supplier number as assigned by the National Supplier Clearinghouse 20083 SUPER PROV REF REFO1 The qualifier for the supervising provider s secondary ID QUALIFIER INVALID identification number information for this claim is invalid Valid Values 1C Medicare provider number 1G Provider UPIN number This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 12 Chapter Eight Edit Number EDIT DESCRIPTION Element D Edit Explanation 20084 SUPERVISING REF02 The secondary identification number indicated on this PROVIDER ID claim for the supervising provider is invalid Verify the INVALID number entered is a valid supplier number as assigned by the National Supplier Clearinghouse This information is not used for DMERC 20085 CLAIM LEVEL CAS The total claim level adjustment amounts indicated on ADJUSTMENT this claim do not equal the total for all submitted INVALID charges for this claim This information is used for Medicare Secondary Payor claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 20086 ADJUSTMENT CAS02 The claim adjustment reason code indicated on this REAS
394. ue entered as a percentage in response to a EXCEEDS question on the CMN sent with this line is invalid If reported MAXIMUM this amount cannot be greater than six positions 11058 PERCENT FRMO5 1 The value entered as the line item charge is invalid This VALUE amount cannot have greater than two positions to the right EXCEEDS MAX of the decimal DECIMAL PLACES 11059 SVC FAC CITY CLMO5 1 If a place of service other than 12 Home is used the facility STATE ZIP city state and zip information must be submitted for this MISSING claim 11060 PLACE OF SV105 If a place of service other than 12 Home is used the facility SERVICE address information must be submitted for this line ADDRESS MISSING 11061 FACILITY C S Z SV105 If a place of service other than 12 Home is used the facility MISSING city state and zip information must be submitted for this line 11062 TRANSACTION BHT04 The creation date for this transaction set was submitted as a CREATION date greater than today s date FUTURE DATE INV This edit indicates an invalid format and should be resolved by contacting your software vendor 11063 CANNOT SEND NM1 The segment providing the receiver name information for gt 1 RECEIVER this transaction exceeds maximum use When this NAME information is reported only 1 occurrence per transaction SEGMENT may be sent Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 185
395. ue entered as the amount to be credited to the MAX AMT credit debit account is not numeric MISSING This information is not used for DMERC 11128 DEBIT MAX AMT02 The value entered as the amount to be credited to the AMT gt 7 credit debit account is invalid This amount cannot be DIGITS greater than 7 positions This information is not used for DMERC 11129 DEBIT MAX AMT02 The value entered as the amount to be credited to the AMT gt 2 credit debit account is invalid This amount cannot contain DECIMALS more than 2 positions to the right of the decimal point This information is not used for DMERC 11130 ADMISSION DTPO3 The admission date for this claim is missing If you have DATE MISSING indicated the place of service to be 21 or you are providing ambulance certification this is a required element This information is not used for DMERC 11131 MISSING CLM CLM11 1 You have indicated this claim to have been related to an 11 VALUE accident by including an accident date When the accident date is submitted the related causes code is a required element Valid Values AA Auto Accident AP Another Party Responsible EM Employment OA Other Accident Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 193 Edit Edit Description Element Edit Explanation Number Segment ID 11132 REND PROV PRV You have included a rendering provider loop with this claim
396. ue representing the patient weight exceeds two EXCEEDS MAX positions to the right of the decimal point DECIMAL PLACES This information is not used for DMERC 10903 TRANSPORT CR106 The value representing the ambulance transport distance DIST exceeds 15 positions EXCEEDS MAXIMUM This information is not used for DMERC 10904 TRANSPORT CR106 The value representing the ambulance transport distance DIST CANNOT exceeds 1 position to the right of the decimal point HAVE gt 1 DEC PLACES This information is not used for DMERC 10905 TREATMENT CR201 The value representing the number of chiropractic service SERIES treatments in the series exceeds 9 positions EXCEEDS MAXIMUM This information is not used for DMERC 10906 TREATMENT CR201 The value representing the number of chiropractic service SERIES treatments cannot contain a decimal point CANNOT HAVE DECIMAL This information is not used for DMERC 10907 TREATMENT CR202 The value representing the total number of treatments EXCEEDS ordered in this series exceeds 15 positions MAXIMUM This information is not used for DMERC 10908 TREATMENT CR202 The value representing the total number of treatments CNT CANNOT ordered in this series cannot contain a decimal point HAVE DECIMAL This information is not used for DMERC 10909 TREATMENT CR206 The value representing the treatment series period exceeds PERIOD CNT 15 positions EXCEEDS MAXIMUM This information is not used for DMERC
397. uide Edits The following pages contain a list of every edit that a submitter may receive along with a brief explanation of the error Please keep in mind when looking up an edit that the edits are separated by level This chapter contains the IG level edits and can occur on any data that was submitted Since this level of editing is validating against the IG we have listed all valid IG values under the valid value section of each edit In an effort to prevent future edits from occurring at the Medicare or DMERC levels we have bolded and italicized the valid DMERC values that may be used for that element For your convenience we have indicated data elements in this section that are not used for DMERC If you receive an edit on data that is not used for DMERC and the information is not needed for another payer please remove the erroneous data and resubmit the file If the data is needed for another payer please correct the claim and retransmit We have also noted those elements that contain data specific to Medicare Secondary Payer Medigap and Payer to Payer transactions These elements should not be used unless the specific condition is met Payer to Payer elements should never be submitted to DMERC by a supplier Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 5 Edit Edit Description Element Edit Explanation Number Segment ID 10001 IN AUTH ISA01 The qualifier indicating authorization information
398. um use SEC EXC MAX When this information is reported only 1 occurrence per USE claim may be used This information is not used for DMERC 10574 ENTITY ID NM101 The qualifier identifying the other payer supervising provider CODE INVALID for this claim is invalid This information is used when a payer is submitting this claim to another payer and should not be submitted by the supplier Valid Value DQ Supervising physician This information is not used for DMERC Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 109 Edit Edit Description Element Edit Explanation Number Segment ID 10575 ENTITY TYPE NM102 The qualifier identifying the other payer supervising provider QUALIFIER type is invalid for this claim INVALID This information is used when a payer is submitting this claim to another payer and should not be submitted by the supplier Valid Value 1 Person This information is not used for DMERC 10576 SUPER PROV NM103 The last name is missing for this claim If you have specified LAST NAME the other payer supervising provider type to be a person MISSING this element must contain the last name of that person This information is used when a payer is submitting this claim to another payer and should not be submitted by the supplier This information is not used for DMERC 10577 OTH PAY REF The segment containing additional other payer supervising SUPER PROV provider identificati
399. umber Segment ID 10442 PURSH SER REF02 The purchased service provider secondary identifier is PROV SEC ID missing for this claim MISSING This information is not used for DMERC 10443 SER FAC LOC NM1 The segment providing the service facility location name EXC MAX USE information for this claim exceeds maximum use When this information is reported only 1 occurrence per claim may be used 10444 ENTITY ID NM101 The qualifier identifying the service facility location for this CODE INVALID claim is invalid Valid Values 77 Service location FA Facility LI Independent lab TL Testing laboratory 10445 ENTITY TYPE NM102 The qualifier identifying the service facility location type is QUALIFIER invalid for this claim INVALID Valid Value 2 Non person entity 10446 ID CODE NM108 The qualifier identifying the service facility location QUALIFIER identification number for this claim is invalid INVALID Valid Values 24 Employer s Identification Number 34 Social Security Number XX Health Care financing Administration National Provider Identifier 10447 ADD SER FAC N2 The segment providing additional service facility location LOC NAME name information for this claim exceeds maximum use EXC MAX USE When this information is reported only 1 occurrence per transaction may be used This information is not used for DMERC 10448 SER FAC LOC N3 The segment providing the service facility location address ADD EXC MAX for this claim exceeds m
400. umber Segment ID 10730 ADJ REF The segment containing the adjusted repriced line item REPRICED LN reference information exceeds maximum use When this ITEM REF NUM information is reported only 1 occurrence per line may be EXC MAX USE used This information is not used for DMERC 10731 NOT USED 10732 ADJ REPRICE REFO2 The adjusted repriced line item reference number is missing LINE REF for this line MISSING This information is not used for DMERC 10733 PRIOR REF The segment containing the prior authorization or referral AUTH REFFER number information exceeds maximum use When this AL NUM EXC information is reported only 1 occurrence per line may be MAX USE used 10734 NOT USED 10735 PRIOR REF02 The prior authorization or referral number is missing for this AUTH REF line MISSING 10736 LINE ITEM REF The segment containing the line item control number CONT EXC information exceeds maximum use When this information is MAX USE reported only 1 occurrence per line may be used 10737 NOT USED 10738 LINE ITEM REF02 The line item control number is missing CONT MISSING This information is not used for DMERC 10739 MAMMOG REF The segment containing the Mammography Certification CERT EXC Number information exceeds maximum use When this MAX USE information is reported only 1 occurrence per line may be used This information is not used for DMERC 10740 NOT USED 10741 MAMMOG REF02 The mammography certification number is missing for this CE
401. unless another payer adjudicated this claim prior to being submitted to Medicare This information is used for Medigap secondary to Medicare claims and should not be submitted unless there is an approved Medigap policy held by this subscriber Valid Values N No benefits have not been assigned to the provider Y Yes benefits have been assigned to the supplier 10498 PAT SIG SOURCE MISSING O104 The code specifying the other insurance patient s signature is missing for this claim If you have indicated that a signature is on file to release any data then you must provide a valid source of signature This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare This information is used for Medigap secondary to Medicare claims and should not be submitted unless there is an approved Medigap policy held by this subscriber Valid Values B Signed signature authorization form or forms for both HCFA 1500 Claim Form block 12 and block 13 are on file C Signed HCFA 1500 Claim Form on file M Signed signature authorization form for HCFA 1500 Claim Form block 13 on file P Signature generated by provider because the patient was not physically present for services S Signed signature authorization form for HCFA 1500 Claim Form block 12 on file www cignamedicare com edi Revised April 2
402. used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 20154 LINE ADJUSTMENT REASON CODE6 INVALID CAS17 The line level claim adjustment reason code indicated on this claim is invalid Verify the claim adjustment reason code was entered as it appears on the explanation of benefits from the primary payer This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare www cignamedicare com edi Revised April 2003 Page 26 Chapter Eight Edit Number EDIT DESCRIPTION ElementID Edit Explanation 20155 SPV PRV LAST NM103 The supervising provider s last name was entered in an NAME INVALID invalid format Verify the first position of the supervising provider s last name is not a space and only contains alpha characters This information is not used for DMERC 20156 DATE TIME DTPO1 The code used to indicate the date of receipt is invalid QUALIFIER INVALID Valid Value RC Receipt date If you receive this edit contact the DMERC EDI Department 20157 DATE TIME PERIOD DTP02 The code used to indicate the format the date was FORMAT QUAL entered to indicate the date of receipt is invalid INVALID Valid Value D8 Date expressed in CCYYMMDD format If you receive this edit contact
403. used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 20147 PATIENT LAST NAME INVALID NM103 The patient s last name was entered in an invalid format Verify the first position of the patient s last name is not a space and only contains alpha characters This information is not used for DMERC 20148 LINE ADJUSTMENT INVALID CAS The total line level adjustment amounts indicated for this line do not equal the line charge This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare 20149 LINE ADJUSTMENT REASON CODE1 INVALID CAS02 The line level claim adjustment reason code indicated on this claim is invalid Verify the claim adjustment reason code was entered as it appears on the explanation of benefits from the primary payer This information is used for Medicare Secondary Payer claims and should not be submitted unless another payer adjudicated this claim prior to being submitted to Medicare Region D DMERC EDI Manual Revised April 2003 Front End Edits Medicare Page 25 Edit Number EDIT DESCRIPTION Element ID Edit Explanation 20150 LINE ADJUSTMENT REASON CODE2 INVALID CAS05 The line level claim adjustment reason code indicated on this cla
404. valid AMT segments to use for this line www cignamedicare com edi Revised April 2003 Page 190 Chapter Seven Edit Edit Description Element Edit Explanation Number Segment ID 11110 THE FIRST HLO1 The billing provider HL segment did not indicate the first HL HLO1 of this file If you receive this error please contact your SEGMENT software vendor VALUE MUST 1 11111 THE 1 HLO1 The value entered in the HL element was not a numeric POSITION OF value If you receive this error please contact your software HLO1 MUST BE vendor NUMERIC 11112 HLO1 HLO1 The submitted file did not have the HL segments properly SEGMENT sequenced When submitting the file please make sure all MUST BE information is complete If you receive this error please INCREMENTE contact your software vendor DBY 1 11113 DATE OF DTPO3 The date of service was missing for this line item This SERVICE IS information is required on every DMERC claim MISSING 11114 INVALID COB AMT A claim level error occurred due to invalid use of a qualifier AMOUNT identifying a COB AMT segment for this claim If you receive QUALIFIER this error please contact your software vendor or refer to the 837 Implementation Guide for valid COB AMT segments to use for this claim 11115 INVALID TEST ISA15 The file submitted was designated as a production file the PROD submitter identified is not allowed to submit productions INDICATOR claims
405. ware may be posted automatically to your accounts receivable and or patient billing system You are given the option of receiving the ERNs on a daily or weekly basis The ERN is the electronic equivalent to a Medicare Remittance Notice MCM 3023 2 Claim Status Inquiry CSI Within three days of a successful transmission you can log into the system and check the status of your claims This is an additional tracking device available once Medicare has received claims Through CSI you will know if your claims have been paid denied or are still pending CSI enables you to search for specific claims and view individual claims MCM 3023 2C CSI is available Monday Saturday from 7 00 a m to 6 00 a m ET You may obtain this software by contacting the EDI Department Beneficiary Eligibility This option is available only to participating suppliers This function allows participating suppliers to send us a file containing the beneficiary name HICN and date of birth MCM 3021 5 3021 6 We will then send a file back including information on the beneficiary s eligibility dates deductible information and HMO enrollment status This function requires a program to build the file to send to us and to read the file when it is returned CIGNA Medicare does not provide this software Region D DMERC EDI Manual Revised June 2002 Chapter Two EDI Products and Services Once you are enrolled and an active electronic biller there are additional EDI
406. will contact you with the results within 3 business days You may also download your Phase II test results for your review Why do I need to send a test with 25 claims Why can t send just one claim The purpose of a test is to make sure you are familiar with how to enter claims in your claims entry billing software When you test with 25 claims that provides for us a better indication of the type of problems you may experience when you begin transmitting your production claims electronically for payment Our intention is to eliminate as many of your questions or problems as possible as this will greatly increase the chance of your claims being accepted into the system for processing www cignamedicare com edi Chapter Five Stratus Network User Guide Introduction The Stratus Network is an asynchronous transmission mailbox system that allows users to dial directly into CIGNA Medicare s Gateway Service This network is used to e Upload your electronic transactions to CIGNA Medicare e Download electronic transactions and reports from CIGNA Medicare This chapter will give you step by step instructions on using the Stratus Network It will go through the process of modem setup dialing in and logon It also shows how to transmit list view and download files For demonstrative purposes we have selected to use HyperTerminal in the following instructions Once you are logged on to the Stratus Network the instructions will be
407. with Receive_XXXXX If not please refer to page 12 of this chapter to change your data type Press Enter ENTER YOUR SELECTION Your mailbox contains the following files 1 MOO1AT_2001 04 03 000001 7 cp ENTER YOUR SELECTION _ 6699 Please enter the MASK for the files you wish to download press lt RETURN gt to list all files or for masking examples 4096 04 03 2001 16 34 11 strm Please enter the number corresponding to your file choice or q to quit This will display the download screen press Enter to see a list of the files available for downloading In your software select Transfer then Receive File This will start the download process When the download process is finished you will receive the message Transfer Complete www cignamedicare con edi Revised June 2002 Page 18 Chapter Five 7 Press Enter after the transfer is complete to return to the Mailbox Access Facility menu If Enter is pressed prior to completion of the file transmission the transmission will be aborted Note Electronic Reports and Electronic Remittance Notice ERN files are stored in your Stratus Network mailbox for seven days including weekends and holidays unless a download was attempted If a download was attempted the file will remain in your Stratus Network mailbox for only three days after the attempt To ensure that the receipt listings are downloaded within this time fram
408. xceed 50 occurrences of this segment 10582 LINE LX01 The service line sequence counter is invalid This element COUNTER must contain only values 1 through 50 INVALID 10583 PROF SV1 The segment containing claim line specific information SERVICE EXC exceeds maximum use When this information is reported MAX USE only 1 occurrence per line may be used 10584 PROD SER ID SV101 1 The qualifier indicating the type of product service code QUALIFIER used for this line is invalid INVALID Valid Values HC Health Care Financing Administration Common Procedural Coding System Codes IV Home Infusion EDI Coalition HIEC product service code N1 National drug code in 4 4 2 format N2 National drug code in 5 3 2 format N3 National drug code in 5 4 1 format N4 National drug code in 5 4 2 format ZZ Mutually defined 10585 LINE ITEM SV102 The service line charges for this line item is missing Each CHG AMT DMERC line item must contain a line charge INVALID 10586 UNIT BASE SV103 The qualifier identifying the type of service units being MEASURE reported is invalid for this line CODE INVALID Valid Values F2 International unit MJ Minutes UN Unit Region D DMERC EDI Manual Revised April 2003 Front End Edits Page 111 Edit Number Edit Description Element Segment ID Edit Explanation 10587 PLACE OF SER INVALID SV105 An invalid place of service has been submitted for this line Valid Valu
409. y only alpha NAME INVALID characters are present This information is not used for DMERC 20128 RENDERING PRVO03 The rendering provider s taxonomy code indicated for PROVIDER this line item is invalid Verify the taxonomy code SPECIALTY INVALID submitted against the taxonomy code list published by Washington Publishing Company To obtain a copy of this list visit their Web site at www wpc edi com This information is not used for DMERC 20129 RENDERING PROV REFO1 The qualifier for the rendering provider s supplier REF ID QUALIFIER number information for this line item is invalid INVALID Valid Value 1C Medicare provider number This information is not used for DMERC 20130 RENDERING PROV REF02 The supplier number indicated on this line item for the SECONDARY ID INVALID rendering provider is invalid Verify the number entered is a valid supplier number as assigned by the National Supplier Clearinghouse This information is not used for DMERC www cignamedicare com edi Revised April 2003 Page 22 Chapter Eight Edit Number EDIT DESCRIPTION Element D Edit Explanation 20131 PURCH SERV PROV REFO1 The qualifier for the purchased service provider s REF ID QUALIFIER secondary identification number information for this line INVALID item is invalid Valid Values 1C Medicare provider number 1G Provider UPIN number This information is not used for DMERC 20132 PURCH SERV PROV REF02 The

DMERC Region D EDI Manual Complete April 2003

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