Claim edit: Invalid HIPPS rate code

Stedi now rejects 837I institutional claims that contain an invalid Health Insurance Prospective Payment System (HIPPS) rate code.

HIPPS rate codes

A HIPPS rate code is a five-character alphanumeric code that tells Medicare which payment group applies to a patient.

Skilled nursing facilities, home health agencies, and inpatient rehabilitation facilities report these codes on institutional claims so the payer can calculate reimbursement.

A HIPPS code sits in the service line's procedure code element, but it isn't a procedure code. Providers get the code from a grouper, software that reads the patient's assessment data and returns the code for the payment group the patient falls into.

HIPPS rate code

You report a HIPPS code by setting the service line's procedure identifier to HP.

Procedure identifier

How the edit works

The Centers for Medicare & Medicaid Services (CMS) publishes all valid HIPPS rate codes in the HIPPS code set. Each code carries an effective date range. CMS retires codes over time.

When you submit a HIPPS rate code on an institutional claim, Stedi compares it against the CMS HIPPS code set. If the code isn't in the set or wasn't active on the claim's date of service, this edit rejects the claim before it reaches the payer. This 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.

If the HIPPS code isn't in the CMS HIPPS code set:

{
  "errors": [
    {
      "code": "33",
      "description": "Invalid HIPPS rate code. The submitted HIPPS code, 11111, on line 1 is not a recognized HIPPS rate code. Correct and resubmit.",
      "followupAction": "Please Correct and Resubmit"
    }
  ]
}

If the HIPPS code exists but wasn't active on the claim's date of service:

{
  "errors": [
    {
      "code": "33",
      "description": "Invalid HIPPS rate code. The submitted HIPPS code, HAEJ1, on line 1 was not active for the date of service. 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, and error message.

If the HIPPS code isn't in the CMS HIPPS code set:

STC*A7>513**U*********Invalid HIPPS rate code. The submitted HIPPS code, 11111, on line 1 is not a recognized HIPPS rate code. Correct and resubmit.~

If the HIPPS code exists but wasn't active on the claim's date of service:

STC*A7>513**U*********Invalid HIPPS rate code. The submitted HIPPS code, HAEJ1, on line 1 was not active for the date of service. Correct and resubmit.~

Related claim edits

Stedi has another edit for HCPCS Level II procedure codes that aren't in the CMS code set. See Invalid HCPCS Level II code.