5010 Electronic Claims Submission 496 Edit And Advanced Diagnostic Imaging Denials
Denial for Advanced Diagnostic Imaging Services
CMS has received reports that providers are receiving denials for advanced diagnostic imaging (ADI) services they are accredited to perform. We have taken action to correct the situation. CMS has instructed all contractors to review each ADI claim denial, and reprocess those claims that were deemed to be incorrectly denied, in a timely manner. Providers do not need to take any action in this situation.
5010 Electronic Claims Submission 496 Edit
With the implementation of Accredited Standards Committee (ASC) X12 Version 5010, the Medicare Administrative Contractors (MACs) have received a large increase in calls from billers regarding the 496 edit, more commonly referred to as "the linkage problem." In some cases, the problem may be the result of a provider not being properly linked to a clearinghouse/vendor submitter in Medicare's system; however, the problem may also be the result of billing errors. The tips that follow will assist you in determining the reason for receipt of a 496 edit and help you understand the resolution of the edit.
Since the 4010 versus 5010 electronic claim formats are not the same, you cannot assume a successful provider and clearinghouse/vendor submitter linkage in 4010 means you should be successfully linked in 5010. Some linkages were initially made nearly a decade ago. We have found that several large clearinghouses that have been repeatedly bought, sold, and combined are now using new submitter numbers.
Prior to the implementation of the Common Edits and Enhancement Module (CEM) software, Medicare contractors maintained their own electronic data interchange (EDI) edits. Now that the 5010 format has a definitive CEM edit to ensure that all linkages are valid, invalid submitter IDs are being stopped for bad linkage.
In addition to the provider and clearinghouse/vendor linkage issue, the 496 edit can also occur because of the following National Provider Identifier (NPI) billing issues:
- Using a Rendering Provider's NPI instead of the Billing Provider NPI (Rendering Provider is not associated with the clearinghouse/vendor submitter)
- Billing Part B services for a provider associated with a Group under his/her Individual NPI when it should be billed under the Group NPI
Resolution of the 496 edit requires evaluation of the Health Care Claims Acknowledgement message (277CA) and all edits incurred in addition to it. While generally a 496 edit may indicate a simple linkage issue, additional edits might focus on the submission of an inappropriate or incorrect NPI as a result of improper billing.
The 277CA, if delivered back to the provider from the clearinghouse/vendor, will have the following message components in the Status Segment (STC) related to a 496 edit:
- First part: Claim Status Category Code = "A8" - Acknowledgement / Rejected for relational field error
- Second part: Claim Status Code = "496" - Submitter not approved for electronic claim submissions on behalf of this entity
- Third part: Entity Identifier Code = "85" - Billing Provider
This message, "A8:496:85," utilizes the Washington Publishing Company (WPC)-maintained National Code values and relays that the claim was rejected for a relationship error between the submitter and the Billing Providers NPI. You will receive this same set of codes for a linkage problem and an improper billing problem (use of rendering versus billing provider NPI, for example, as described above).
Clearinghouse/Vendor evaluation of all edits received should be completed before asking for linkage problem resolution from your MAC.
Contact your MAC EDI support line after researching the nature of your 496 edits for assistance with the provider and clearinghouse/vendor submitter linkage and the collection of the CMS-required Provider Authorization to bill for each customer. The MAC EDI support lines are available at http://www.CMS.gov/ElectronicBillingEDITrans/03_EDISupport.asp.