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Back  RFI # 145: Claim rejection level

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Submitter

sherry kirkpatrick

Description

Does HIPAA state a claim must be rejected at the claim level or at the ST/SE level to be HIPAA compliant? Or, stated another way, if a plan does not reject at the claim level and only the ST/SE level, are they still HIPAA compliant?

Submitter Assigned Keywords

Response

The implementation guides for the 837 do not address rejections. Good EDI practice would only reject a transaction (ST to SE) if the error in a claim was an X12 syntax error that prohibited the translator from processing the transaction.

Recommendation

Individual claims that have errors other than an X12 syntax issue that prohibits processing the transaction can be rejected using a 277 or 824 transaction. If the claim is rejected for contractual or coverage reasons, that claim should be reported on an 835 transaction.
Submission 11/12/2004
Status Date 1/21/2005
Status F - Final
Primary References
Document 004010X096
SectionST/SE
Page12
Set IDST/SE