NextGen Knowledge Center

System-Level Claim Edit Descriptions

System-level claim edits are hard-coded in NextGen® Enterprise PM. They are a set of edits that run during the Claim Edits and Billing processes, but are not controlled by settings in the Claim Edits Library.

Below is a list of the various messages, by severity, that may display on the Claim Production Status Report as a result of a system-level claim edit.

Build

System-level claim edits with a severity of Build display messages in red text, indicating a problem that must be resolved before a claim can be created for the encounter.
  • A maximum of four diagnoses are supported on paper 1500 claims.
  • A maximum of four diagnoses are supported on ADA claims.
  • Billing a Physician Assistant with this payer requires the encounter to have a Supervisor Physician.
  • Clinic Rate CPT4 is alphanumeric. You must manually enter the appropriate value code and amount.
  • Invalid claim form type XXX please confirm alt payer and SIM maintenances claim form setup.
  • Invalid claim form type XXX, please confirm SIM maintenance claim form setup.
  • Missing claim form type, please confirm alt payer and SIM maintenance claim form setup.
  • No charges were selected for processing.
  • No payer is specified to receive this claim.
  • Self-Pay Billing requires at least one charge on the Encounter.
  • Self-Pay Billing requires all charges to have a rendering physician.
  • The location of charge must match the encounter location for a UB92 encounter.

Critical

System-level claim edits with a severity of Critical display messages in red text, indicating a problem that must be resolved before a claim can be created for the encounter.
  • ANSI 5010 Requirement: Bill-To location address (2010AA N403) requires 9-digit ZIP code, current value is XXX.
  • ANSI 5010 Requirement: Billing provider address (2010AA N403) requires 9-digit ZIP code, current value is XXX.
  • ANSI 5010 Requirement: Billing provider NPI (2010AA NM109) is required.
  • ANSI 5010 Requirement: Billing provider Tax id or SSN (2010AA REF) is required.
  • ANSI 5010 Requirement: Billing Tax Id is required.
  • ANSI 5010 Requirement: Patient address (XXX N403) requires 9-digit ZIP code when Place of Service is Home, current value is XXX.
  • ANSI 5010 Requirement: Release of Information (2300 CLM09) must be Yes (Y) or Release of Information (I), current value is XXX.
  • ANSI 5010 Requirement: Service Facility address (XXX N403) requires 9-digit ZIP code, current value is XXX.
  • ANSI 5010 Requirement: Special program code (2300 CLM12) is invalid: XXX.
  • Claim suspended due to existence of suspend effective date at Provider-Payer-Location level.
  • DME payer information was not located.

Custom

System-level claim edits with a severity of Custom display messages in back text, indicating a problem that must be resolved before a claim can be created for the encounter.
  • No specified charge amounts found on the encounter to process.
  • Provider XXX was not found on database lookup.

Information

System-level claim edits with a severity of Information display messages in green text. These are informational messages indicating no problems were found, and depending on the message, a claim may or may not have been created for the encounter.
  • Alternate Payer claim did not go through Encounter Rate Billing due to library setting.
  • Claim successfully created.
  • Claim successfully created. ER SIM not inserted due to Exempt indicators.
  • Claim successfully passed edits.
  • Claim suppressed due to Multi-Day Encounter Status of Multi-No.
  • Claim suppressed due to payer master indicator.
  • Claim suppressed for containing only voided charges.
  • Claim suppressed for only containing voided charges.
  • Claim was suppressed due to Encounter Rate Exempt indicator.
  • Claim was suppressed due to error on insertion of Encounter Rate SIM.
  • Claim was suppressed due to Multi-Day Encounter Status of Undecided.
  • Clinic Rate CPT4 is alphanumeric. You must manually enter the appropriate value code and amount.
  • Primary Claim was suppressed due to another primary Encounter Rate Claim existing for this patient/practice/payer/encounter date.
  • No errors found.
  • No errors found. ER SIM not inserted due to Encounter Rate library settings.
  • Non-Encounter Rate Claim successfully created.
  • Secondary Claim not created because not all line item have payments.
  • Secondary Claim not created due to other same day encounters having no posted line item payments.
  • Secondary Claim was suppressed by Encounter Rate library settings.
  • Secondary Claim was suppressed due to another secondary Encounter Rate Claim existing for this patient/practice/payer/encounter date.
  • Self-Pay Encounter Billed.
  • Self-Pay Encounter successfully passed edits.
  • There were no valid SIMs in the Encounter Rate Library.
  • Zero balance claim was suppressed.

Tech

System-level claim edits with a severity of Tech display messages in red text, indicating a problem that must be resolved before a claim can be created for the encounter.
  • Claim type is NULL or Blank.
  • Contact Tech Support: COB order is corrupt.
  • Duplicate DEFAULT Referring Physician IDs are setup in Provider Master.
  • Duplicate encounter numbers were found on database lookup.
  • Duplicate Patient Person_id was found on database lookup.
  • Duplicate Payers were found on database lookup.
  • Duplicate practice locations found on database lookup.
  • Duplicate providers were found on database lookup.
  • Duplicate Referring Physicians were found on database lookup.
  • Duplicate Referring Physician IDs are setup in Provider Master.
  • Duplicate Rendering Physicians were found on database lookup.
  • Encounter location was not found on database lookup.
  • Encounter not found on database lookup.
  • Encounter Payer information not found on database lookup.
  • Error occurred on encounter location database lookup.
  • Error writing claim.
  • Group Record not found on database lookup.
  • Media Type is NULL or Blank.
  • Multiple encounter locations were found on database lookup.
  • No charges found to process.
  • Patient Person_id was not found on database lookup.
  • Payer has not been setup with practice level information.
  • Payer not found on database lookup.
  • Practice location was not found on database lookup.
  • Provider/Payer Record not found on database lookup.
  • Referring Physician not found on database lookup.
  • Rendering Physician not found on database lookup.
  • Unsupported Claim Type.

Warning

System-level claim edits with a severity of Warning display messages in blue text. These are warning messages indicating potential problems were found, but a claim is still created for the encounter.
  • Claim created. Edits have been disabled for this payer.
  • Edits have been disabled for this payer.
  • More than 25 principle procedures codes are attached to encounter XX, only 25 will make the claim.
  • Primary claim was not located. Charge rendering is the claim rendering.