Claim edit: Prior authorization number matches the referral number

Stedi now rejects 837P professional, 837D dental, and 837I institutional claims that report the same value for the prior authorization number and the referral number.

Prior authorizations and referrals

A prior authorization is the payer's approval of a service before the provider performs it. The payer assigns a number to each approval. You can report the prior authorization number at the claim level or on a service line.

Prior authorization number

Service line prior authorization number

A referral is a provider's recommendation that the patient can see another provider – for example, a primary care provider who sends the patient to a specialist. Some plans, such as HMOs, require a referral before they cover a specialist visit. Each referral has its own number.

Referral number

Service line referral number

How the edit works

A prior authorization and a referral are different approvals, so their numbers shouldn't match. If you submit a claim with the same value in both fields, the payer may reject the claim.

The edit compares the numbers at the claim level and on each service line. When a service line reports only one of the numbers, the edit compares it to the other number at the claim level. The comparison ignores letter case.

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

How you get the error depends on how you submit the claim.

{
  "errors": [
    {
      "description": "Invalid Prior Authorization number. The prior authorization number, PA20261009, cannot be the same value as the referral number. Correct and resubmit."
    }
  ]
}

{
  "errors": [
    {
      "code": "33",
      "description": "Invalid Prior Authorization number. The prior authorization number, PA20261009, cannot be the same value as the referral number. Correct and resubmit.",
      "followupAction": "Please Correct and Resubmit"
    }
  ]
}

STC*A8>761>QC*[DATE]*U*[AMOUNT]******A8>252>QC**Invalid Prior Authorization number. The prior authorization number, [PRIOR AUTHORIZATION NUMBER], cannot be the same value as the referral number. Correct and resubmit.~

Related claim edits

Stedi has another edit for service line referral numbers. See Service-line referral number without a claim-level referral number.