Claim edit: Insurance type code not allowed for the primary payer

Stedi now rejects 837P professional and 837D dental claims that include an insurance type code for the primary payer.

What is an insurance type code?

Insurance type codes are only required in coordination of benefits (COB) scenarios where Medicare – or a Medicare Administrative Contractor (MAC) – is not the primary payer.

In COB scenarios, the patient is covered by insurance from more than one payer. The primary payer pays first, then the secondary payer, and so on. Payer responsibility level codes, also called payment responsibility sequence number codes, indicate this order. A code of P indicates the primary payer.

An insurance type code indicates why Medicare is not the primary payer on a claim. For example, code 12 means the patient has an employer group health plan that pays before Medicare.

Claims should only include an insurance type code when providing information about the non-primary payer, such as the secondary or tertiary payer. You can provide an insurance type code in two places, depending on whether it's for the payer you're sending the claim to or one of the patient's other payers:

Insurance type code for the payer you’re sending the claim to

Insurance type codes for the patient’s other payers

How the edit works

A claim shouldn’t include an insurance type code for the primary payer. If it does, the payer may reject the claim.

This edit catches the issue before the claim reaches the payer. It prevents payer rejections, which take longer to resolve and delay payment for the provider.

Rejection errors

If you submit a claim using Stedi's Claim Submission API endpoints and the claim fails the edit, you'll get back an error response in real time. The response includes details in the errors array:

{
  "errors": [
    {
      "code": "33",
      "description": "Invalid insurance type code usage. When the payer is primary for the subscriber, an insurance type code is not allowed. Correct and resubmit.",
      "followupAction": "Please Correct and Resubmit"
    }
  ]
}

{
  "errors": [
    {
      "code": "33",
      "description": "Invalid insurance type code usage. When the payer is primary for the subscriber, an insurance type code is not allowed. Correct and resubmit.",
      "followupAction": "Please Correct and Resubmit"
    }
  ]
}

{
  "errors": [
    {
      "code": "33",
      "description": "Invalid insurance type code usage. When the payer is primary for the subscriber, an insurance type code is not allowed. Correct and resubmit.",
      "followupAction": "Please Correct and Resubmit"
    }
  ]
}

If you submit a claim using SFTP and the claim fails the edit, Stedi will reject the claim with a 277CA claim acknowledgment. The acknowledgment will include a related claim status category code, claim status code, entity identifier code, and error message:

STC*A7>578>HK*[DATE]*U*[AMOUNT]******A8>742**Invalid insurance type code usage. When the payer is primary for the subscriber, an insurance type code is not allowed. Correct and resubmit

STC*A7>578>HK*[DATE]*U*[AMOUNT]******A8>742**Invalid insurance type code usage. When the payer is primary for the subscriber, an insurance type code is not allowed. Correct and resubmit

STC*A7>578>HK*[DATE]*U*[AMOUNT]******A8>742**Invalid insurance type code usage. When the payer is primary for the subscriber, an insurance type code is not allowed. Correct and resubmit