New claim edit: Patient’s date of birth and gender required

Stedi now rejects 837P professional, 837D dental, and 837I institutional claims that are missing the patient’s date of birth or gender.

Payers use the patient’s date of birth and gender to match the claim to the correct patient record. If either field is missing, the payer will reject the claim, which can cause delays.

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

Patient vs. subscriber vs. dependent
In a health insurance claim, there are three distinct roles:

• The subscriber is the person who holds the insurance policy. They’re also called the insured, the primary policyholder, or the primary cardholder.
  
  

• A dependent is someone covered under the subscriber’s plan, such as a spouse or child.
  
  

• The patient can be either the subscriber or a dependent, depending on who received care.

For example, if a child receives dental care, the child is the patient even though the parent is the subscriber.

Claims must include the patient’s date of birth and gender – not just the subscriber’s – so the payer can identify the correct person.

How the edit works
A claim can include information for both the subscriber and the dependent, if applicable. You only include the dependent’s information if the dependent is the one who received care and the dependent doesn’t have their own member ID.

As part of the edit, Stedi checks the patient’s information to ensure the claim includes the patient's date of birth and gender:

• If the subscriber is the patient: The edit requires the subscriber’s date of birth and gender.
  
  

• If the dependent is the patient: The edit requires the dependent’s date of birth and gender and ignores the subscriber's date of birth and gender.

If the patient’s date of birth or gender is missing, Stedi rejects the claim so you can correct and resubmit it before it reaches the payer.

Rejection errors
If you submit a claim that fails the edit using Stedi’s claim submission APIs or professional claim form, you’ll get back an error message in real time. If you’re using a JSON API endpoint, the response includes an error in the errors array:

{
  "errors": [
    {
      "code": "33",
      "description": "The patient's date of birth and gender are both missing. Correct and resubmit.",
      "followupAction": "Please Correct and Resubmit"
    }
  ]
}

If you submit a claim that fails the edit using SFTP, Stedi will reject the claim with a 277CA claim acknowledgment. The acknowledgment will contain a related claim status category code, claim status code, and error message. You can use the error message to correct and resubmit the claim.