Claim edit: Invalid EPSDT certification and condition indicator combination

Stedi now rejects 837P professional and 837I institutional claims where the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) certification indicator and the first EPSDT condition indicator contradict each other.

What are EPSDT certification and condition indicators?

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) is a mandatory federal Medicaid benefit for children and other beneficiaries under the age of 21. It covers routine checkups and screenings, plus any follow-up care those screenings show the patient needs.

837P professional and 837I institutional claims include dedicated fields for EPSDT services. A payer uses these fields to decide how coverage rules apply and whether to approve the services on the claim:

• EPSDT Certification Condition Code Applies Indicator, also called the EPSDT certification indicator – A yes/no flag for whether the patient needs follow-up care based on the screening. A value of N indicates the patient does not need follow-up care.

• EPSDT condition indicators – Two-character codes that describe whether the patient was referred for follow-up care and the outcome of that referral. For example: AV (Referral Available – Not Used), S2 (Under Treatment), or ST (New Services Requested). A value of NU (Not Used) indicates the screening didn’t result in a referral for follow-up care. A claim can contain one or more EPSDT condition indicators.

EPSDT certification indicator

EPSDT condition indicators

How the edit works

This edit compares the EPSDT certification indicator against the first EPSDT condition indicator:

• If the first condition indicator is NU (Not Used), the EPSDT certification indicator must be N.

• If the EPSDT certification indicator is N, the first condition indicator must be NU.

If the EPSDT certification indicator and first EPSDT condition indicator contradict each other, Stedi rejects the claim. This prevents later 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 first condition indicator is NU but the EPSDT certification indicator is not N:

{
  "errors": [
    {
      "code": "33",
      "description": "Invalid EPSDT Condition Indicator. When the EPSDT condition indicator is 'NU' (not used), the EPSDT certification code applies indicator must be 'N' (no). Submitted indicator is 'Y'. Correct and resubmit.",
      "followupAction": "Please Correct and Resubmit"
    }
  ]
}

If the EPSDT certification indicator is N but the first EPSDT condition indicator is not NU:

{
  "errors": [
    {
      "code": "33",
      "description": "Invalid EPSDT Certification Condition Code Applies Indicator. When the EPSDT certification applies indicator is 'N' (no), the EPSDT condition indicator must be 'NU' (not used). Submitted indicator is 'AV'. 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 first condition indicator is NU but the EPSDT certification indicator is not N:

STC*A7>527*[DATE]*U*[AMOUNT]******A8>564**Invalid EPSDT Condition Indicator. When the EPSDT condition indicator is 'NU' (not used), the EPSDT certification code applies indicator must be 'N' (no). Submitted indicator is 'Y'. Correct and resubmit.~

If the EPSDT certification indicator is N but the first EPSDT condition indicator is not NU:

STC*A7>564*[DATE]*U*[AMOUNT]******A8>527**Invalid EPSDT Certification Condition Code Applies Indicator. When the EPSDT certification applies indicator is 'N' (no), the EPSDT condition indicator must be 'NU' (not used). Submitted indicator is 'AV'. Correct and resubmit.~

Resolution tips

To avoid triggering this edit, match the claim’s EPSDT certification indicator and its first EPSDT condition indicator:

• Use EPSDT certification indicator N with an EPSDT condition indicator of NU (Not Used).

• Use EPSDT certification indicator Y with an EPSDT condition indicator of AV (Referral Available – Not Used), S2 (Under Treatment), or ST (New Services Requested).