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.
