EDI rejections do occur, so it's important to understand why they happen and how to prevent them in the future.
When you submit a claim electronically, an 837 EDI claim submission file is created and sent through the clearinghouse to the payer. While the application completes a basic error check before the claim is sent, every payer has their own requirements for EDI claim. Both the clearinghouse and the payer's EDI department will scrub the claim looking for errors.
If an error is found, an error file is sent back to our system. Once received, a link to the error will be generated under the Electronic Claim Errors section of the dashboard.
EDI Rejection Page
The EDI Rejection page shows what error message(s) were received. The system will try to match the error to a help article that provides an explanation of the error means and how to correct it. These articles can also be found in the Knowledge Base.
Call the Clearinghouse or Payer
If there is no related article or if you still are not sure how to correct the error, you will need to call the clearinghouse or the payer. Remember, the error messages come from the clearinghouse and insurance company directly. The application simply displays the messages it receives.
In order to determine which entity to call, you will need to try and locate the Payer Reference Number.
Locate Payer Reference Number
- From the EDI Rejection screen, locate the Edit Claim Information box.
- Select the View Status Messages link. A new window will appear.
- Messages received from the clearinghouse and payer will be listed in ascending order, with the most recent at the bottom. Locate the most recent entry and select View Details. A .txt file will be downloaded to your computer.
- When you open the file, there will be a lot of information that appears to be incoherent. Feel free to copy-and-paste the data into a word processing application (i.e. Microsoft Word). This might make it easier to locate the needed fields.
- If you are unsure what clearinghouse the claim was initially sent to, find the [CLEARINGHOUSE] item.
- AV = Availity
- JP = Jopari
- Pinpoint the [PAYER_REF] item. If there is an entry for this field, you will know that the claim made it to the payer and that you should contact their EDI Department. The number located in this field is the Payer Claim Reference Number, you'll need to provide this information to the payer to discuss the rejection with them. If the [PAYER_REF] field is blank, continue to the next step.
- If the claim was sent to Availity, locate the [EDI_FILE]. This is a batch number you can provide them to locate the claim and discuss the rejection.
- If the claim was sent to Jopari, provide them with the client's name and your Jopari username for assistance.
If you are given information about what loop and segment the error is located in, you can find more information on correcting those errors here: EDI (837) Files.
|Phone Prompt||Option 3, Then 2||Option 3, Then 2|
Resubmission vs. Corrected Claims
If the claim was rejected, you can typically resubmit the claim as new, because it was never accepted by the payer for adjudication. For more information, please see: Resubmission vs. Corrected Claim.
Note: If you need to make any demographic changes, they should be updated in WebPT as well.