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 claim. Although this is not a HIPAA requirement, it 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 an original and voided claim is present. In this case, the Claim Frequency Code in CLM05-03 would be different (1 and 8), but CLM01 would be the same. Therefore, Compliance Checking requires the entire CLM segment to be unique in reporting results at a claim rejection level. Suppose the concatenated value of all CLM elements is not unique. In that case, Claim Level Rejection is terminated for the transaction with the duplicate CLM segments, and a message will appear in the compliance check summary file that indicates that the Claim Level Rejection process has been 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. For the Claim Level Rejection process to extract any rejected claims, all of the errors in the transaction set must occur at the claim level or lower.
• The Claim Level Rejection parameter is configurable and optional. The default parameter setting is to not execute the Claim Level Rejection process.
• All 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.