WPS Military and Veterans Health EDI front-end editing changes for TRICARE East Region 837 Professional claims, effective December 15, 2018. Historically, many claims pend in the claims processing system because they were submitted with an incorrect Billing Provider Name and/or National Provider Identifier (NPI), or the rendering provider segment is missing when a clinic submitted the claim.

WPS notified you of changes to the EDI front-end and allow you , our trading partners time to implement changes.   WPS will be using the National Plan and Provider Enumeration System (NPPES) as the resource for validating NPI data, therefore it is important that provider’s review their NPPES records for accuracy (https://npiregistry.cms.hhs.gov/).  The NPPES resourced data will be updated on a monthly (by the 22nd) basis.

The following edits will be applied to 837 Professional claims with place of service 11 (office) only:

1. When a Billing NPI is submitted in NM109 of the 2010AA Billing Provider Loop:

o    If the NPI submitted is a Type 1, then the Sole Proprietor field must be a Yes.

o    If the NPI submitted is a Type 2, then the Rendering Provider Segment must be submitted in Loop 2310B or 2420A.

Note: The Rendering Provider NPI will not be required at this time, but the segment must be provided with the Rendering Provider Name.

2. As a reminder, the Billing Provider Address Loop 2010 must have a physical address, and if the services rendered were not at this address, then the Service Facility Loop 2310C must be submitted. If there is more than one Service Facility for the claim, then use the Service Facility Loop 2420C.

Error messages on your 277CA claims acknowledgment and suggested resolutions

STC*A7:562:85 – Invalid Billing NPI.   Verify the billing provider NPI is valid.  If valid, verify it is active on NPPES.

STC*A8:562:85 – Invalid billing provider relationship.  Verify the billing provider is a solo practitioner or an organization.  If a member of a group, the group’s information, including NPI, should be in the 2010AA; and rendering provider information in 2310B.  If you are a solo practitioner, update your NPPES record.

STC*A8:562:82 – Invalid rendering provider relationship.  Verify that the rendering provider NPI is present.   Rendering provider is required for taxonomy codes Multi-Specialty - 193200000X and Single Specialty - 193400000X. 

 STC*A7:562:82 – Verify the rendering provider NPI is valid.  If valid, verify it is active on NPPES.

*Please note, claims may have previously pended and processed (including payment). 

This notification is to inform you that we have recently experienced a production issue that may have impacted some of your claims.

If you received a rejection due to member related issues and recognize that the rejection is invalid, please resubmit those claims.

Please note: Due to this production issue there has been a delay in processing claim files from Tuesday 6/5/18 through today 6/8/18, and the response files pertaining to these files will be posted to your “out” folder as soon as possible. 

We apologize for any inconvenience this may have caused.

Thank you.

Information Technology Department
Partnership HealthPlan of California

McLaren Health Plan has identified an issue with claims rejecting an error. Claims submitted to Optum on August 4^th, 2017 to September 11^th, 2017 rejected in error at the payer. The claims are currently processing at the Mclaren as normal so please disregard the rejection messages.  

 The affected claims were rejected with the following error messages:

            This Segment Has Data Element Errors

            This segment Exceeds Maximum Use

            This Data element has an Invalid code value

Next Steps:

• McLaren is working to resolve the issue
• Claims that rejected are from 08/4/2017 to 9/11/2017 and are currently in process
• No provider action is needed at this time