Claim edit: Missing insurance type code when Medicare is a non-primary payer
Stedi now rejects 837P professional and 837D dental claims where Medicare appears as a non-primary payer and the insurance type code is missing.
How the edit works
In coordination of benefits (COB) scenarios, a claim may list multiple payers. For example, a patient may have a commercial payer as their primary payer and Medicare as their secondary payer. You indicate whether a payer is primary, secondary, tertiary, and so on using a payment responsibility sequence number code, also called a payment responsibility level code.
Payment responsibility level
| Claim type | JSON API field | X12 element |
|---|---|---|
| 837P professional | claimInformation.otherSubscriberInformation[].paymentResponsibilityLevelCode | SBR-01 (Payer Responsibility Sequence Number Code) of Loop 2320 (Other Subscriber Information) |
| 837D dental | claimInformation.otherSubscriberInformation[].paymentResponsibilityLevelCode | SBR-01 (Payer Responsibility Sequence Number Code) of Loop 2320 (Other Subscriber Information) |
Any non-primary payers on a claim must have a claim filing indicator. The indicator tells you what type of payer or plan it is. For example, CI is for a commercial insurance company.
Claim filing indicator
| Claim type | JSON API field | X12 element |
|---|---|---|
| 837P professional | claimInformation.otherSubscriberInformation[].claimFilingIndicatorCode | SBR-09 (Claim Filing Indicator Code) of Loop 2320 (Other Subscriber Information) |
| 837D dental | claimInformation.otherSubscriberInformation[].claimFilingIndicatorCode | SBR-09 (Claim Filing Indicator Code) of Loop 2320 (Other Subscriber Information) |
If Medicare is a non-primary payer on the claim, the claim filing indicator must be MA (Medicare Part A) or MB (Medicare Part B). In these cases, an insurance type code is also required.
The insurance type code indicates why Medicare isn't the primary payer. For example, code 12 means the patient has an employer group health plan.
Insurance type code
| Claim type | JSON API field | X12 element |
|---|---|---|
| 837P professional | claimInformation.otherSubscriberInformation[].insuranceTypeCode | SBR-05 (Insurance Type Code) of Loop 2320 (Other Subscriber Information) |
| 837D dental | claimInformation.otherSubscriberInformation[].insuranceTypeCode | SBR-05 (Insurance Type Code) of Loop 2320 (Other Subscriber Information) |
If the insurance type code is missing, the payer may reject the claim.
This edit catches the issue before the claim reaches the payer. It prevents payer rejections, which are slower 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:
{
"errors": [
{
"code": "33",
"description": "Missing required insurance type code. Insurance type code (Loop 2320 SBR05) is required when the payer is Medicare and Medicare is not the primary payer. 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:
STC*A6:578*[DATE]*U*[AMOUNT]********Missing required insurance type code. Insurance type code (Loop 2320 SBR05) is required when the payer is Medicare and Medicare is not the primary payer. Correct and resubmit.~