Claim edit: Multiple prior authorization or referral numbers on a service line
Stedi now rejects 837P professional and 837D dental claims that report more than one prior authorization number or referral number on a service line for the payer you're sending the claim to.
Service line prior authorization and referral numbers
A prior authorization is the payer's approval of a service before the provider performs it. A referral is a provider's recommendation that the patient see another provider. Some plans, such as HMOs, require a referral before they cover a specialist visit. The payer assigns a number to each.
Service line prior authorization number
| Claim type | JSON API field | X12 element |
|---|---|---|
| 837P professional | Claim Submission API: claimInformation.serviceLines[].serviceLineReferenceInformation.priorAuthorization[]CMS-1500 API: serviceLines[].priorAuthorizations[] | REF*G1 (Prior Authorization) of Loop 2400 (Service Line Number) |
| 837D dental | claimInformation.serviceLines[].serviceLineReferenceInformation.priorAuthorization[] | REF*G1 (Prior Authorization) of Loop 2400 (Service Line Number) |
Service line referral number
| Claim type | JSON API field | X12 element |
|---|---|---|
| 837P professional | claimInformation.serviceLines[].serviceLineReferenceInformation.referralNumber[] | REF*9F (Referral Number) of Loop 2400 (Service Line Number) |
| 837D dental | claimInformation.serviceLines[].serviceLineReferenceInformation.referralNumber[] | REF*9F (Referral Number) of Loop 2400 (Service Line Number) |
How the edit works
Per X12 standards, a prior authorization or referral number without a payer identifier belongs to the payer you're sending the claim to. A service line can have only one of each for that payer.
To report another payer's prior authorization number, such as the primary payer's in a coordination of benefits (COB) claim, include that payer's identifier in otherPayerPrimaryIdentifier (REF-04 with qualifier 2U). In the CMS-1500 API, use otherPayerPrimaryId. The JSON API doesn't support payer identifiers for referral numbers, so report only one per service line.
If a service line reports more than one, the payer may reject the claim.
This edit catches the issue before the claim reaches the payer. It prevents payer rejections, which take longer to resolve and delay payment for the provider.
Rejection errors
How you get the error depends on how you submit the claim.
If you submit a claim using the Create Professional Claim (CMS-1500) JSON endpoint and the claim fails the edit, you'll get back a 201 response with an errors array in real time:
{
"errors": [
{
"description": "Invalid Prior Authorization Number. Only one prior authorization number for the destination payer is allowed per service line. Other payers' numbers need a payer identifier (2U). Line 1 reports 2 without one. Correct and resubmit."
}
]
}The CMS-1500 endpoint doesn't accept service line referral numbers, so it can't fail the referral number edit.
If you submit a claim using Stedi's other 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.
For prior authorization numbers:
{
"errors": [
{
"code": "33",
"description": "Invalid Prior Authorization Number. Only one prior authorization number for the destination payer is allowed per service line. Other payers' numbers need a payer identifier (2U). Line 1 reports 2 without one. Correct and resubmit.",
"followupAction": "Please Correct and Resubmit"
}
]
}For referral numbers:
{
"errors": [
{
"code": "33",
"description": "Invalid Referral Number. Only one referral number for the destination payer is allowed per service line. For other payers' numbers, include the payer identifier (2U). Line 1 reports 2 without one. 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.
For prior authorization numbers:
STC*A7>252>HK**U*******A8>247**Invalid Prior Authorization Number. Only one prior authorization number for the destination payer is allowed per service line. Other payers' numbers need a payer identifier (2U). Line 1 reports 2 without one. Correct and resubmit.~For referral numbers:
STC*A7>761>HK**U*******A8>247**Invalid Referral Number. Only one referral number for the destination payer is allowed per service line. For other payers' numbers, include the payer identifier (2U). Line 1 reports 2 without one. Correct and resubmit.~Related claim edits
Stedi has other edits for service line prior authorization and referral numbers. See Prior authorization number matches the referral number and Service-line referral number without a claim-level referral number.
