Electronic claim loop format - some important points and tips

Errors identified for business level edits performed prior to the SUBSCRIBER LOOP (2000B) will result in immediate file failure at that point. When this occurs, no further editing will be performed beyond the point of failure.

The billing provider must be associated with an approved electronic submitter. Claims submitted for billing providers that are not associated to an approved electronic submitter will be rejected

The maximum number of characters to be submitted in any dollar amount field is seven characters. Claims containing a dollar amount in excess of 99,999.99 will be rejected.

Medicare does not support the submission of foreign currency. Claims containing the 2000A CUR segment will be rejected

Claims that contain percentage amounts with values in excess of 99.99 will be rejected

For the exception of the CAS segment, all amounts must be submitted as positive amounts. Negative amounts submitted in any non-CAS amount element will cause the claim to be rejected.

Claims that contain percentage amounts cannot exceed two positions to the left or the right of the decimal. Percent amounts that exceed their defined size limit will be rejected

Contractor name 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.

Only loops, segments, and data elements valid for the HIPAA Professional Implementation Guides will be translated. Submitting data not valid based on the Implementation Guide will cause files to be rejected.

Medicare requires the National Provider Identifier (NPI) be submitted as the identifier for all claims. Claims submitted with legacy identifiers will be rejected. (Non-VA contractors)

National Provider Identifiers will be validated against the NPI algorithm. Claims which fail validation will be rejected

Medicare does not require taxonomy codes be submitted in order to adjudicate claims, but will accept the taxonomy code, if submitted. However, taxonomy codes that are submitted must be valid against the taxonomy code set published at http://www.wpc-edi.com/codes/taxonomy. Claims submitted with invalid taxonomy codes will be rejected.

 All dates that are submitted on an incoming 837 claim transaction must 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).

A. You may send up to four modifiers; however, the last two modifiers will not be considered. The Contractors processing system will only use the first two modifiers for adjudication and payment determination of claims. -OR-

B. You may send up to four modifiers; however, the last three modifiers will not be considered. The Contractors processing system will only use the first modifier for adjudication and payment determination of claims.