Assumptions

Claim Level Rejection is only provided for the 837, Professional, Dental, and Institutional claims transactions. It is available for 5010 versions of the claims transactions. It is ignored if the input HIPAA EDI data is not a claim transaction.

Assumptions about the Claim Level Rejection parameter are described here.

• When healthcare claims transactions are processed, the HIPAA Guidelines recommend that the value in CLM01 be unique for each individual claim. Although this is not a HIPAA requirement, this can be used as a means for claims to be uniquely identified, and reported, in an automated system. However, there are cases where Claims with the same CLM01 could be present in the input transmission being validated. One scenario is when there is an original and voided claim present. In this case Claim Frequency Code in CLM05-03 would be different (1 and 8), but CLM01 would be the same. Therefore, Compliance Checking requires that the entire CLM segment is unique to report results at a claim rejection level. If the concatenated value of all CLM elements is not unique, Claim Level Rejection is terminated for the transaction with the duplicate CLM segments and a message appears in the compliance check summary file that indicates that the Claim Level Rejection process is terminated.
• If a transaction fails any level of structure checking, then the entire transaction set is rejected. This is the same behavior that was exhibited before Claim Level Rejection was introduced. To successfully run Claim Level Rejection, the loop id must be available for inspection. If the data fails the structure checking step, the loop id is not determinable.
• If a transaction is structurally sound, and all errors within the transaction occur at the claim level or below, then the claim, or claims, in error are rejected and the valid claims are written to the valid file.
• If any error occurs at a level higher than the provider in the transaction set, the entire transaction is rejected. All of the errors in the transaction set must occur at the claim level or lower for the Claim Level Rejection process to extract any rejected claims.
• The Claim Level Rejection parameter is configurable and optional. The default parameter setting is to not execute the Claim Level Rejection process.
• All of the valid claims are reformed into a new transaction with the EDI structures adjusted so that the transaction passes HIPAA compliance to the validation level requested. These valid claims are listed in the compliance_check_valid.out file.
• Rejected claims are reformed into a new transaction with the EDI structures adjusted so that the transaction only fails HIPAA compliance for the same reason, or reasons, as the original claim rejection. Rejected claims are listed in the compliance_check_invalid.out file.