Quality health plans & benefits Healthier living Financial well-being Intelligent solutions
Rejected/returned claims resolution tips 1. U se this guide, along with your 277 Health Care Claim Acknowledgement, to assist you in resolving some of the most common rejected/returned claims. You can request the 277 Health Care Claim Acknowledgment from your vendor. 2. Locate the reason your claim was rejected or returned and resubmit the claim after taking the suggested action, if appropriate.
Category/status/entity codes
Definitions
Translation
Suggested action
A1:19:PR Coventry redirects
This claim/encounter has been received. Coventry claim.
Claim is being internally routed to the Coventry claims system.
No action is required.
A3:562:85 Unprocessable claim
Acknowledgement/returned as unprocessable claim. The claim/ encounter has been rejected and has not been entered into the adjudication system. Entity’s National Provider Identifier (NPI). Billing provider.
This claim has been returned because there is an issue with the NPI.
Make sure the NPI entered is valid. It must have 10 digits. Use leading zeros if necessary.
A7:24:TU Third-party organization (TPO) ID invalid
Acknowledgment/rejected for invalid information. Third-party organization (TPO) ID is invalid.
TPO ID is invalid.
Make sure the TPO ID should be submitted, and if so, make sure the TPO ID is correct. Note: This is a field in the HCP segment of the claim/encounter.
Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company and its affiliates (Aetna). 83.03.818.1 B (12/16)
Category/status/entity codes
Definitions
Translation
Suggested action
A7:33 Insured ID missing or invalid
Acknowledgment/rejected for invalid information. Insured ID missing or invalid.
The ID number of the insured person is missing or invalid.
Make sure the insured’s ID number is entered and correct.
A7:128:85 Provider TIN invalid
Acknowledgment/rejected for invalid information. Provider tax identification number (TIN) invalid.
Provider TIN is invalid.
Make sure the provider’s TIN is valid.
A7:188 Statement period start and/or end date(s) invalid
Acknowledgement/rejected for invalid information. The claim/encounter has invalid information, as specified in the status details, and has been rejected. Statement from – through dates.
Statement date is invalid. The statement start or end date is a future date.
Make sure the start and end dates are correct and are not future dates.
A7:189 Admit date is missing or invalid
Acknowledgment/rejected for invalid information. For hospital inpatient claims, a valid admission date is required.
Hospital inpatient claims require a valid admission date. It cannot be left blank and cannot be greater than the current date.
Make sure the admission date is correct for the inpatient hospital claim and is not a future date.
A7:228 Type of bill invalid
Acknowledgment/rejected for invalid information. The claim/encounter has invalid information, as specified in the status details, and has been rejected. Type of bill for institutional claim.
The bill type is not a valid code.
Check the bill type code and confirm it is valid.
A7:255 Diagnosis code invalid
Acknowledgment/rejected for invalid information. The claim/encounter has invalid information, as specified in the status details, and has been rejected. Invalid diagnosis code.
ICD-9 diagnosis code(s) is invalid based on the effective date for ICD-10 coding requirement.
Make sure the diagnosis code is correct for the date of service. Note: As of October 1, 2015, ICD-10 codes are required.
A7:402 Claim total charges
Acknowledgment/rejected for invalid information. The claim/encounter has invalid information, as specified in the status details, and has been rejected. Note: At least one other status code is required to identify which amount element is in error.
The total amount submitted on the claim is zero.
1. Make sure the claim contains an actual dollar amount. 2. Double-check the math.
A7:453 Modifier invalid
Acknowledgement/rejected for invalid information. The claim/encounter has invalid information, as specified in the status detail, and has been rejected. Procedure code modifier(s) for service(s) rendered.
The procedure code modifier submitted does not exist.
Make sure the procedure code modifier submitted is valid.
83.03.818.1 B (12/16)
Category/status/entity codes
Definitions
Translation
Suggested action
A7:454 CPT code missing or invalid
Acknowledgement/rejected for invalid information. The claim/encounter has invalid information, as specified in the status details, and has been rejected. Procedure code for services rendered.
Procedure code for services rendered is invalid.
Make sure the CPT procedure code submitted is valid.
A7:454 ICD procedure code invalid
Acknowledgment/rejected for invalid information. The claim/encounter has invalid information, as specified in the status details, and has been rejected. ICD procedure code for services rendered.
ICD procedure code is invalid for the date of service.
Make sure the ICD procedure code is valid for the date of service.
A7:455 Revenue code is missing or invalid
Acknowledgement/rejected for invalid information. The claim/encounter has invalid information, as specified in the status details. The claim/encounter has been rejected. Revenue code for services rendered.
There’s a conflict between the hospital bill and the revenue codes.
1. If the claim is a facility claim, confirm the bill type matches the services rendered. 2. If the bill type is for inpatient services, confirm inpatient revenue codes are on the claim. 3. If the bill type is for outpatient services, remove room and board revenue codes if any are on the claim.
A7:488 Diagnosis code is missing
Acknowledgment/rejected for invalid information. Diagnosis code is missing.
The primary diagnosis code can’t be an accident diagnosis code.
Make sure the primary code is a non-accident diagnosis code.
A7:507 HCPCS (Healthcare Common Procedure Coding System)
Acknowledgement/rejected for invalid information. The claim/encounter has invalid information, as specified in the status details, and has been rejected.
The HCPCS code is missing or invalid.
Make sure the HCPCS code is present and valid.
A7:508 Diagnosis and/or procedure code invalid
Acknowledgment/rejected for invalid information. The claim/encounter has invalid information, as specified in the status details, and has been rejected. ICD-9. Note: At least one other status code is required to identify the related procedure code or diagnosis code.
Diagnosis and/or procedure codes include a combination of ICD-9 and ICD-10 codes.
Make sure the diagnosis and/or procedure code for the date of service is correct. Note: As of October 1, 2015, ICD-10 codes are required.
83.03.818.1 B (12/16)
Category/status/entity codes
Definitions
Translation
Suggested action
A7:700 Procedure code invalid
Acknowledgment/rejected for invalid information. The claim/encounter has invalid information, as specified in the status details and has been rejected. ICD-10. Note: At least one other status code is required to identify the related procedure code or diagnosis code.
Diagnosis and/or procedure codes include a combination of ICD-9 and ICD-10 codes.
Make sure the procedure code for the date of service is correct. Note: As of October 1, 2015, ICD-10 codes are required.
A7:720 Occur code invalid
Acknowledgement/returned as unprocessable claim. The claim/encounter has been rejected and has not been entered into the adjudication system.
The occurrence code is either missing or invalid.
Make sure the National Uniform Billing Committee occurrence code is entered and correct.
Additional resources available at Washington Publishing Company: www.wpc-edi.com/reference.
www.aetna.com ©2016 Aetna Inc. 83.03.818.1 B (12/16)
