How to Address Transaction Set Level Rejections (Availity-4010)


PLEASE NOTE:
Steps to address Transaction Set Level Rejections from Availity for ANSI 5010 can be found in the following article:



Symptoms:

All claims in an ANSI 4010 batch sent to the Availity clearinghouse are rejected.  The rejection message on Claims tab of each visit is from an ACK report.  All claims in the batch have the same message, which looks like this:

 

Problem Description:

At least one visit in the batch has a problem that caused the entire batch to be rejected by Availity at the clearinghouse level.  This is most often caused by invalid characters (i.e. punctuation) in the patient or claim information, and/or data that does not meet the requirements for a given segment (i.e. state or ZIP code has too many characters).

Resolution:

To find the claim(s) causing the rejection:

 

1.       Open any claim that has the rejection message and go to the Claims tab.  Note the file name of the report with the rejection message.  You may need to expand the File Name column to see the entire report file name.

 

2.       Go to EDI Response Management and open the report:

a.       In the File Name field, enter the name of the report with the rejection messages.

b.       Check the “Include Archived” box in the lower left corner of the window.

c.       Click “OK” to search for the file.

 

3.       Right-click the report file name and select “View”.

a.       If prompted, select “Select the program from a list”.

b.       Select a simple word processing program (i.e. Wordpad) to use this program to open the ACK report.

c.       Click OK.  The file will open in the selected program.

 

4.       The ACK report will have a section that looks something like this:

 

AK1*HC*75732~

AK2*837*000000001~

AK3*N4*2784*2010BC*8~

AK4*2*156*5*ORE~

AK5*R*5~

AK9*R*1*1*0~

SE*8*1000~

GE*1*1~

 

The AK3 line tells you what loop and segment of the batch file caused the batch to reject, as well as the line number of the batch file that includes the problematic loop and segment.  The format of the line is:

 

                        AK3*(segment)*(line number)*(loop)*(error code)

 

In the example above, the problem is in loop 2010BC, N4 segment, and it appears on line 2784 of the batch file.

 

The AK4 line tells you what data caused the problem (when appropriate).  The string between the fourth asterisk and the tilde at the end of the line is the problematic data.  In the example above, the string “ORE” is what caused the batch to reject.

 

Note: the report may list multiple AK3 and AK4 lines.  If this is the case, then there are multiple issues in the batch file that must be addressed.

 

Make a note of the line number(s), loop(s), segment(s) and bad data string(s) from the AK3 and AK4 lines of the report.

 

5.       Go back to the Claims tab of the visit and double-click the batch filename.  It will open in EDI Submission Management.

 

 

6.       Right-click the batch in EDI Submission Management and select View.

a.       If prompted, select “Select the program from a list”.

b.       Select a word processing program (i.e. Microsoft Word) to use this program to open the batch file.

c.       Click OK.  The file will open in your word processing program.

 

Please note: steps 7 through 10 include instructions specific to Microsoft Word.  If you use a different word processing program, please refer to your program’s documentation to determine how to replace all tilde characters (~) with line breaks, and how to add line numbers to your file.

 

7.       Go to the Edit menu and select “Replace” (or just press CTRL-H).  A “Find and Replace” window will pop up.

 

8.       In the “Find what:” field, enter:  ~

In the “Replace with:” field, enter: ^l (shift-6 followed by a lowercase L).

 

9.       Click “Replace All”.  All tildes will be replaced with line breaks.

 

10.   Add line numbers to the file.

a.       Go to the File menu and select Page Setup.

b.       Click the Layout tab.

c.       In the lower left section of the window, click the Line Numbers button.

d.       Check the “Add Line Numbers” box.

e.       Check the “Continuous” radio button.

f.        Click OK.

 

11.   Go to the line number from the AK3 line of the report (from step 3).  Because the first “line” of the claim file generally spans a few lines of the document, the data causing the issue will usually be 3 to 5 lines down from the reported line number.

 

12.   From the line with the problem-causing data, you can find the claim number.  The claim number is in a CLM segment.  If the loop number (from the AK3 line of the report, step 3) is less than 2300, the CLM segment will appear below the line with the bad data.  If the loop is 2300 or greater, the CLM segment will appear above the line with the bad data.  The CLM segment will look like this

 

CLM*123456*50***12::1*Y*A*Y*Y*B

 

The number just after “CLM*” is the ticket that caused the batch rejection.  In the example above, the ticket number is 123456.

 

Please note: if your ACK report has multiple AK3 lines, repeat steps 10 and 11 for each error.

 

Now that you know which ticket(s) caused the batch rejection, you can use the rest of the information from the AK3 and AK4 lines of your ACK report to determine what in the claim is causing the problem.  The loop and segment information from the AK3 line(s) tells you where to look.

 

Some common problem areas include:

 

Loop 2010AA: Billing Provider loop

Note: If the responsible provider on the visit is filing as an individual, check the responsible provider information.  If the provider files as part of a group, check the company on the visit.

Loop 2010BA: Subscriber (insured party) loop

Loop 2010BB: Payer Name (insurance carrier) loop

Loop 2010BC: Responsible Party (guarantor) loop

Loop 2010CA: Patient loop

Loop 2310A: Referring Provider (and/or PCP) loop

Loop 2310B: Rendering Provider loop

Loop 2310D: Facility Location loop

Loop 2330A: Other Subscriber Name loop (information from patient’s other insurance)

Loop 2330B: Other Payer Name (insurance carrier) loop

 

Segment NM1: Name

Segment N3: Address

Segment N4: City/State/ZIP code

 

Issues in segments NM1 and N3 are usually caused by invalid characters (punctuation).

Issues in segment N4 can be caused by invalid characters, a state abbreviation with more than 2 characters (i.e. ORE instead of OR), or a ZIP code with less than 5 digits.

 

 

Loop 2300: Claim Information loop

            Segment CLM: Claim information

This is often caused by an invalid Resubmission Code on the Filing(1) tab of the visit – resubmission code should only be one digit, and should generally be either 1 (original claim) or 7 (corrected claim).

            Segment NTE: Claim Note

                        This is usually caused by invalid characters on Notes tab of the visit.

 

 

Loop 2400: Service Line loop

            Segment NTE: Line note

This is usually caused by invalid characters in the procedure notes.

Charge tab > Modify Procedure > Charge 1 tab > Notes

 

 

Use the information from the AK3 line(s) of the report to determine where the problem lies.  When you find the bad data from the AK4 line(s), you know you’ve found the cause of the batch rejection.  Once the issue(s) that caused the batch to reject are resolved, all of the claims in the batch should be re-batched and re-sent.

Posted Friday, October 10, 2008 by Jaime Hinkle
https://hiskb.healthcois.com/KnowledgebaseArticle10221.aspx