New Unbilled Claim Edits

1. The procedure code is missing one of the following values: NDC Qty, NDC Unit of Price or Unit of Measure

A.     Applicable only to electronic claims

B.     If any of the procedure codes you are billing include NDC information, complete NDC information is required. Which includes:

i.   NDC Price (may be submitted as $0.00)

ii.  NDC Unit of Measure (Milligrams, grams, etc)

iii. NDC Quantity and must be greater than zero

C.     NDC information is specified in Master Files > Transaction Codes > Charge codes

D.    Any charges entered without complete information must be corrected before submission

i.   Please Note: If “Unit of Measure” was part of the missing information, the charge must be deleted and reposted. It cannot be edited

2. A street address is required for provider, group and facility

A.     5010 requires all provider, group and facility addresses to be physical addresses. The edit will trigger if a PO Box is supplied as part of the address

3. Payment reason codes are missing or do not balance

A.     The edit will trigger if you are billing the secondary carrier and no payment reason codes were supplied

B.     If payment reason codes are supplied but don’t balance, the edit will be triggered.

C.     In the illustration below we show you a generic example of how a balanced claim should look like

D.    The formulas used for the illustration above are these:

i. Charge – Allowed = Contractual Obligation Payment Reason Code

ii. Allowed – Payment = Patient Responsibility Reason Code

4.      Contracted date is missing for Provider ID or Group ID

A.     Edit is triggered if an ID is loaded for a provider, group or carrier and no contracted date is supplied

5.      Facility is missing NPI information

A.     Only applicable to 5010 eClaims

B.     Only applicable if the facility master file has “Include on Claims” set to Yes

C.     Edit is triggered when the above is true and the NPI information is missing from the facility master file attached to the visit



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