New claim edit: Invalid claim frequency code and patient status code combination

Stedi now rejects 837I institutional claims that contain a conflicting claim frequency code and patient status code combination.

How the edit works

In an institutional claim, the claim frequency code tells the payer whether a claim is an original claim, a correction, or part of an ongoing stay.

Claim frequency code

The claim’s patient status code describes the patient's condition at the end of the claim’s billed period. It tells the payer whether the patient was discharged, transferred, or still admitted.

Patient status code

The claim frequency code and patient status code must be compatible. For example, if a claim uses a claim frequency code of 1 (Admit thru Discharge Claim) – meaning the patient’s stay is finished – the patient status code shouldn’t be 30 (Still a Patient), which means the patient is still in the facility.

If the claim frequency code and patient status code are conflicting, the payer may reject the claim. That rejection can delay payment to the provider.

This edit – the industry term for an automated validation rule – catches the issue before the claim reaches the payer.

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 combination of claim frequency and patient status. The submitted patient status code 30 indicates the patient is still admitted, which conflicts with the claim frequency code 1 indicating a final bill. Correct and resubmit.",
      "followupAction": "Please Correct and Resubmit"
    }
  ]
}

{
  "errors": [
    {
      "code": "33",
      "description": "Invalid combination of claim frequency and patient status. The submitted patient status code 30 indicates the patient is still admitted, which conflicts with the claim frequency code 1 indicating a final bill. Correct and resubmit.",
      "followupAction": "Please Correct and Resubmit"
    }
  ]
}

{
  "errors": [
    {
      "code": "33",
      "description": "Invalid combination of claim frequency and patient status. The submitted patient status code 30 indicates the patient is still admitted, which conflicts with the claim frequency code 1 indicating a final bill. 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>535>QC*[DATE]*U*[AMOUNT]********Invalid combination of claim frequency and patient status. The submitted patient status code 30 indicates the patient is still admitted, which conflicts with the claim frequency code 1 indicating a final bill. Correct and resubmit

STC*A7>535>QC*[DATE]*U*[AMOUNT]********Invalid combination of claim frequency and patient status. The submitted patient status code 30 indicates the patient is still admitted, which conflicts with the claim frequency code 1 indicating a final bill. Correct and resubmit

STC*A7>535>QC*[DATE]*U*[AMOUNT]********Invalid combination of claim frequency and patient status. The submitted patient status code 30 indicates the patient is still admitted, which conflicts with the claim frequency code 1 indicating a final bill. Correct and resubmit