New claim edits: Invalid subscriber individual relationship codes

Stedi now rejects 837P professional, 837D dental, and 837I institutional claims that contain an invalid individual relationship code for the subscriber.

Individual relationship codes

In a healthcare claim, the subscriber is the person who holds the insurance policy. The subscriber is also called the policyholder or primary cardholder.

The subscriber is not always the patient. For example, a dependent, such as a spouse or child, may receive care through an employee’s insurance. In that case, the employee is the subscriber, even though they’re not receiving care.

Claims indicate the relationship between the subscriber and the patient using an individual relationship code in the subscriber’s section. This code tells the payer whether the patient is the subscriber themselves or a dependent covered under the same plan.

How the edits work

In a claim, if the subscriber’s individual relationship code is 18 (Self), it means the subscriber is the patient. In these cases, the claim must not include information for a dependent. Similarly, if a claim does not include a dependent’s information, the subscriber’s individual relationship code must be 18.

If a claim mixes the subscriber’s individual relationship code and dependent information incorrectly, payers may reject the claim. This can delay payment for the provider.

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

Where to find the subscriber’s individual relationship code

• JSON API

  • Professional claims JSON endpoint: claimInformation.otherSubscriberInformation[].individualRelationshipCode

  • Dental claims JSON endpoint: claimInformation.otherSubscriberInformation[].individualRelationshipCode

  • Institutional Claims JSON endpoint: claimInformation.otherSubscriberInformation.individualRelationshipCode

• Raw X12

  • Professional claims: SBR02 (Individual Relationship Code) of Loop 2000B (Subscriber Hierarchical Level)

  • Dental claims: SBR02 (Individual Relationship Code) of Loop 2000B (Subscriber Hierarchical Level)

  • Institutional claims: SBR02 (Individual Relationship Code) of Loop 2000B (Subscriber Hierarchical Level)

• Stedi portal

  • Professional claims using the CMS-1500 form: Box 6 – Patient Relationship to Insured

The subscriber’s individual relationship code must not be 18

If you submit a claim with a dependent’s information and the subscriber’s individual relationship code is set to 18, Stedi’s JSON and X12 Claim Submission API endpoints return an error message in real time. The response includes details in the errors array:

{
  "errors": [
    {
      "code": "33",
      "description": "Invalid Subscriber Individual Relationship Code. Subscriber's individual relationship code cannot be '18' (Self) when subscriber is not the patient (as indicated by the dependent loop). 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 include a related claim status category code, claim status code, and error message:

STC*A7:N156*[DATE]*IL*[AMOUNT]********Invalid Subscriber Individual Relationship Code. Subscriber's individual relationship code cannot be '18' (Self) when subscriber is not the patient (as indicated by the dependent loop). Correct and resubmit.~

The subscriber’s individual relationship code must be 18

If you submit a claim without a dependent’s information and the subscriber’s individual relationship code is missing or not set to 18, Stedi’s JSON and X12 Claim Submission API endpoints return an error message in real time. The response includes details in the errors array:

{
  "errors": [
    {
      "code": "33",
      "description": "Missing Subscriber Individual Relationship Code. Subscriber's individual relationship code must be '18' (Self) when subscriber is the patient (as indicated by the absence of dependent information). 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 include a related claim status category code, claim status code, and error message:

STC*A6:N156*[DATE]*IL*[AMOUNT]********Missing Subscriber Individual Relationship Code. Subscriber's individual relationship code must be '18' (Self) when subscriber is the patient (as indicated by the absence of dependent information). Correct and resubmit.~