DME EDI Edits for May 23 NPI Requirement
Effective May 23, 2008, the National Provider Identifier (NPI) is the only provider identifier allowed on Medicare claims. The following new and modified front-end EDI edits will be implemented for claims received on/after May 23, 2008 to validate that only the NPI is reported for all provider identifier fields.
4010A1 Claim Edits
EDIT # |
EDIT DESCRIPTION |
ELEMENT/ SEGMENT ID |
EDIT EXPLANATION |
20138 |
SUPER PROV ID QUALIFIER INVALID |
2420D. |
As of May 23, 2008, the Supervising Provider ID Qualifier (NM108) must be “XX” to reflect the NPI in the NM109. Qualifiers for legacy ID numbers (EIN or SSN) will no longer be allowed in NM108. |
20177 |
REFERRING PROVIDER INVALID |
2310A. |
As of May 23, 2008, the Referring Provider ID Qualifier (NM108) must be “XX” to reflect the NPI in the NM109. Qualifiers for legacy ID numbers (EIN or SSN) will no longer be allowed in NM108. |
20179 |
PURCHASED SERVICE PROV INVALID |
2310C. |
As of May 23, 2008, the Purchased Services Provider ID Qualifier (NM108) must be “XX” to reflect the NPI in the NM109. Qualifiers for legacy ID numbers (EIN or SSN) will no longer be allowed in NM108. |
20180 |
SERVICE FACILITY LOC INVALID |
2310D. |
As of May 23, 2008, the Service Facility Location ID Qualifier (NM108) must be “XX” to reflect the NPI in the NM109. Qualifiers for legacy ID numbers (EIN or SSN) will no longer be allowed in NM108. |
20181 |
SUPERVISING PROVIDER INVALID |
2310E. |
As of May 23, 2008, the Supervising Provider ID Qualifier (NM108) must be “XX” to reflect the NPI in the NM109. Qualifiers for legacy ID numbers (EIN or SSN) will no longer be allowed in NM108. |
20183 |
PURCHASED SERVICE PROV INVALID |
2420B. |
As of May 23, 2008, the Purchased Services Provider ID Qualifier (NM108) must be “XX” to reflect the NPI in the NM109. Qualifiers for legacy ID numbers (EIN or SSN) will no longer be allowed in NM108. |
20184 |
SERVICE FACILITY LOC INVALID |
2420C. |
As of May 23, 2008, the Service Facility Location ID Qualifier (NM108) must be “XX” to reflect the NPI in the NM109. Qualifiers for legacy ID numbers (EIN or SSN) will no longer be allowed in NM108. |
20185 |
ORDERING PROV ID QUAL INVALID |
2420E. |
As of May 23, 2008, the Ordering Provider ID Qualifier (NM108) must be “XX” to reflect the NPI in the NM109. Qualifiers for legacy ID numbers (EIN or SSN) will no longer be allowed in NM108. |
20186 |
REFERRING PROVIDER INVALID |
2420F. |
As of May 23, 2008, the Referring Provider ID Qualifier (NM108) must be “XX” to reflect the NPI in the NM109. Qualifiers for legacy ID numbers (EIN or SSN) will no longer be allowed in NM108. |
20348 |
OTHER PAYER REFERRING PROV ID INVALID |
2330D. |
As of May 23, 2008, the qualifier “1C” (Medicare Provider Number) or “1G” (Provider UPIN Number) will no longer be allowed. |
20349 |
OTHER PAYER PURCHASED SERV PROV ID INVAL |
2330F. |
As of May 23, 2008, the qualifier “1C” (Medicare Provider Number) or “1G” (Provider UPIN Number) will no longer be allowed. |
20350 |
OTHER PAYER SERV FACILIT PROV ID INVALID |
2330G. |
As of May 23, 2008, the qualifier “1C” (Medicare Provider Number) or “1G” (Provider UPIN Number) will no longer be allowed. |
20351 |
OTHER PAYER SUPERVISING PROVIDER INVALID |
2330H. |
As of May 23, 2008, the qualifier “1C” (Medicare Provider Number) or “1G” (Provider UPIN Number) will no longer be allowed. |
20352 |
REFERRING PROVIDER SECONDARY ID INVALID |
2310A. |
As of May 23, 2008, the qualifier “1C” (Medicare Provider Number) or “1G” (Provider UPIN Number) will no longer be allowed. |
20353 |
PURCHASED SERVICE PROV SECOND ID INVALID |
2310C. |
As of May 23, 2008, the qualifier “1C” (Medicare Provider Number) or “1G” (Provider UPIN Number) will no longer be allowed. |
20354 |
SERVICE FACILITY LOCATION SEC ID INVALID |
2310D. |
As of May 23, 2008, the qualifier “1C” (Medicare Provider Number) or “1G” (Provider UPIN Number) will no longer be allowed. |
20355 |
SUPERVISING PROVIDER SECONDARY ID INVALID |
2310E. |
As of May 23, 2008, the qualifier “1C” (Medicare Provider Number) or “1G” (Provider UPIN Number) will no longer be allowed. |
20356 |
PURCHASED SERVICE PROV SECOND ID INVALID |
2420B. |
As of May 23, 2008, the qualifier “1C” (Medicare Provider Number) or “1G” (Provider UPIN Number) will no longer be allowed. |
20357 |
SERVICE FACILITY LOCATION SEC ID INVALID |
2420C. |
As of May 23, 2008, the qualifier “1C” (Medicare Provider Number) or “1G” (Provider UPIN Number) will no longer be allowed. |
20358 |
 SUPERVISING PROVIDER SECONDARY ID INVALID |
2420D. |
As of May 23, 2008, the qualifier “1C” (Medicare Provider Number) or “1G” (Provider UPIN Number) will no longer be allowed. |
20359 |
ORDERING PROVIDER SECONDARY ID INVALID |
2420E. |
As of May 23, 2008, the qualifier “1C” (Medicare Provider Number) or “1G” (Provider UPIN Number) will no longer be allowed. |
20360 |
REFERRING PROVIDER SECONDARY ID INVALID |
2420F. |
As of May 23, 2008, the qualifier “1C” (Medicare Provider Number) or “1G” (Provider UPIN Number) will no longer be allowed. |
20361 |
PS101 REFID NOT EQ PURCH SRV PROV SEC ID |
2420B. |
The NPI submitted in the 2420B NM109 must equal the identifier submitted in 2400.PS101. |
20362 |
BILLING PROVIDER SECONDARY ID INVALID |
2010AA. |
As of May 23, 2008, the qualifier “1C” (Medicare Provider Number) or “1G” (Provider UPIN Number) will no longer be allowed. |
20363 |
PAY-TO PROVIDER SECONDARY ID INVALID |
2010AB. |
As of May 23, 2008, the qualifier “1C” (Medicare Provider Number) or “1G” (Provider UPIN Number) will no longer be allowed. |
20364 |
RENDERING PROVIDER SECONDARY ID INVALID |
2310B. |
As of May 23, 2008, the qualifier “1C” (Medicare Provider Number) or “1G” (Provider UPIN Number) will no longer be allowed. |
20365 |
RENDERING PROV SECONDARY ID INVALID |
2420A. |
As of May 23, 2008, the qualifier “1C” (Medicare Provider Number) or “1G” (Provider UPIN Number) will no longer be allowed. |
20366 |
OTHER PAYER RENDERING SECONDARY ID INVALID |
2330E. |
As of May 23, 2008, the qualifier “1C” (Medicare Provider Number) or “1G” (Provider UPIN Number) will no longer be allowed. |
Below is an additional front-end EDI edit that will be modified to require the NPI:
Edit 40014, for the 2420E loop, Ordering Provider Name, will set when NM108=24 (employer’s identification number) or 34 (Social Security Number). NM108 must equal XX and NM109 must contain a 10-digit NPI.
NCPDP Claim Edits
Below are new front end EDI edits that will occur for NCPDP claims received on/after May 23, 2008 when an NPI is not reported. The edit number, description of the edit and reject code is provided.
Edit # |
Description |
Reject Code |
65091 |
Provider ID Qualifier (465-EY) field contains a value other than '05' (NPI) |
EY |
65092 |
Primary Care Provider ID Qualifier (468-2E) field contains a value other than '01' (NPI) |
2E |
65093 |
Provider ID Qualifier (465-EY) field contains value '05' (NPI) and the value in the Provider ID (444-E9) field has an invalid first digit or is not 10 numeric characters |
E9 |
The following new front-EDI edits will occur for NCPDP claims received on/after May 23, 2008 when the NPI is not reported.
Edit # |
Description |
65010 |
Service Provider ID Qualifier (202-B2) field on the Transaction Header segment contains values other than '01' (NPI) |
65028 |
Prescriber ID Qualifier (466-EZ) field on the Prescriber segment contains values other than '01' (NPI) |
As a reminder, current NCPDP edits that will remain after May 23, 2008 are as follows:
Edit # |
Description |
Reject Code |
65094 |
Provider ID Qualifier (465-EY) field contains value '05' (NPI) and the value in the Provider ID (444-E9) field has an invalid check digit |
E9 |
65095 |
Primary Care Provider ID Qualifier (468-2E) field contains value '01' (NPI) and the value in the Primary Care Provider ID (421-DL) field has an invalid first digit or is not 10 numeric characters |
35. |
Posted on May 6, 2008