Enhanced claim validation

Enhanced claim validation uses hundreds of additional edits (the industry term for validation rules) to increase claim acceptance rates.

When a claim fails enhanced validation, Stedi does not submit it to the payer. Instead, Stedi returns a synchronous response with a detailed error message you can use to diagnose and fix the issue.

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Enable enhanced validation

To enable enhanced validation for the Professional Claims or Professional Claims Raw x12, set the Stedi-Validation header to snip.

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Example validation error

The following sample error message resulted from a SNIP validation Level 3 failure. Specifically, the total claim charge amount did not match the total of all service line charge amounts reported in the claim.

{
  "errors": [
    {
      "id": "481",
      "note": "The total claim charge amount must balance to the sum of all service line charge amounts reported in the Professional Service (SV1) segments for this claim.",
      "loop_context": null,
      "validations": [
        {
          "Any": [
            {
              "All": [
                {
                  "Rule": "Expected 'C:2300:1300:CLM-02' (100) to be equal to '[\"P:2400:3700:SV1-02\"]' (92)"
                }
              ]
            }
          ]
        }
      ]
    }
  ]
}

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Automatic fixes

When you enable enhanced validation, Stedi also automatically fixes common errors before sending the claim. These include invalid date/time formats and character encoding issues.

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Rejection monitoring

Stedi automatically monitors your 277 rejections to proactively build new rules for enhanced validation based on previous failures.

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SNIP validation

SNIP (Strategic National Implementation Process) validation is a set of guidelines established by the Workgroup for Electronic Data Interchange (WEDI) and the Centers for Medicare & Medicaid Services (CMS) to ensure that healthcare claims meet specific standards and rules.

Stedi’s enhanced validation tests SNIP levels 1-7, which include a wide range of requirements.

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Level 1: EDI syntax

Determine whether the generated EDI file meets basic X12 standard syntax rules, such as:

• Are the data elements within the specified maximum and minimum lengths?
• Are all of the required segments and elements present?
• Are all of the loops in the correct order?
• Are delimiters used correctly?

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Level 2: HIPAA syntax

Determine whether the generated EDI file complies with HIPAA-specific rules, such as:

• Are all of the required segments and elements present in the claim? For example, the request must include the billing provider’s address information and tax identification number.
• Are all required qualifiers included correctly? For example, the request must include a qualifier code that indicates whether the subscriber is an individual person or an non-person entity, such as a company.
• Are the parent-child relationships between segments and elements correct? For example, the Claim Information loop contains child loops with information about various providers, ambulance pickup/dropoff (if applicable), and the service facility.

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Level 3: Balancing

Determine whether the financial data in the claim is computed correctly, such as whether claim totals match the sum of the service line items.

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Level 4: Situations

Determine whether the claim meets the situational rules specified in the HIPAA implementation guide.

Situational rules describe scenarios where when A information is present, B information must also be present. For example, when a claim is for an accident, the request must include the accident date.

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Level 5: External code sets

Determine whether the values from external code sets used in the claim are valid. This includes:

• Code sets such as ICD, CPT, and NDC as well as status codes and adjustment reason codes.
• Code formats. For example, ICD-10 codes must be alphanumeric with a specific length.

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Level 6: Product type/Type of service

Determine whether the claim meets the requirements for the specific type of service or product being billed. For example, if the claim is for an ambulance service, does the request include information about the transport reason and distance traveled?

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Level 7: Payer-specific

Determine whether the claim meets additional, payer-specific requirements. For example, Vermont Medicaid requires all uppercase characters in the request. Stedi’s enhanced validation checks whether claims to Vermont Medicaid use all uppercase characters and returns a warning if not.