Claims Edit Misfire Causes 450,000 Claims Rejections Nationwide

Health insurer Humana recently notified a number of physician organizations and other affected entities about a glitch in its request for implementation of a valid 5010 transaction claims edit that ultimately resulted in the rejection of some 450,000 claims.

Affected health care claims were submitted between April 26 and May 10 to Humana's designated claims clearinghouse, Availity LLC.

According to Humana, any physician who submits claims directly to Availity -- a secure health information network that connects physicians with health plans to facilitate the electronic exchange of business and clinical information -- or who submits claims through a clearinghouse that forwards claims to Availity likely will experience rejected claims.

In response, Availity has instructed physicians to resubmit claims that were affected by enforcement of the edit. Availity does not have the capability to recover and reprocess rejected claims.

The problem occurred after Humana requested that Availity begin enforcing a new 5010 transaction standards claims edit required by the Health Insurance Portability and Accountability Act (HIPAA). The edit requires that each diagnosis code on a claim link to the corresponding procedure code on that claim.

A claims edit serves as a filter that enables a computer software program to determine if a submitted claim meets the necessary conditions and criteria that allow payment processing to continue.

According to Humana and Availity, there is no question that the edit is valid because it is clearly outlined in the HIPAA 5010 transaction implementation guide and required by CMS. However, CMS recently announced that it was re-evaluating its policy on this particular edit, making Availity's enforcement of the claims edit problematic.

Physicians who submit claims directly to Availity and who have further questions about rejected claims can contact Availity by phone at (800) 282-4548 or online.

Physicians who submit claims through clearinghouses that partner with Availity should contact those clearinghouses directly to clear up questions regarding rejected claims.