Eligibility Error Messages

Change Healthcare Eligibility error messages and categories

Most providers’ offices ask for a considerable amount of information during the intake process for a new medical encounter. Since this by definition, eliminates the possibility of sending a minimal query as an Eligibility request, accuracy in data entry is important for a successful Eligibility transaction. Avoid cutting corners in this area.

Error Message Formatting

Error Message

Description

{ "field": "provider.validProviderCode", "description": "Allowed Values are: 'AD' Admitting, 'AT' Attending, 'BI' Billing, 'CO' Consulting, 'CV' Covering, 'H' Hospital, 'HH' Home Health Care, 'LA' Laboratory, 'OT' Other Physician, 'P1' Pharmacist, 'P2' Pharmacy, 'PC' Primary Care Physician, 'PE' Performing, 'R' Rural Health Clinic, 'RF' Referring, 'SB' Submitting, 'SK' Skilled Nursing Facility, 'SU' Supervising" }

Many error messages describe simple follow-up actions and show the X12 loop where the incorrect field appears. For most errors, you can just correct the JSON field (in the request body) that is listed in the response, or edit using your console workflow. For some request fields, errors list the permissible values.

If a data entry mistake occurs in this field, you will receive this error. Since a provider will often be of one specific type, the providerCode value should be a commonly understood value among provider employees whose job involves claims processing. Since providerCode is an optional value, consider removing optional values from the request before re-sending. Depending on the data that is needed to fully define the procedure for payer analysis, this may not be an option.

Required Value Errors

If you submit a request body that is missing a required value, you will receive a response similar to the following:

📘

NOTE

For more information, please see Contents of the Eligibility Request Body.

The message also tells you which fields are permissible for identification.

  1. In the following example, provide organizationName or firstName and lastName for the medical provider.
{
    "provider":
        {
            "firstName": "medical",
            "lastName": "group",
            "npi": "0123456789"
        },

At a minimum, for the provider object, you must provide the npi and organizationName. If the provider is an individual, the firstName and lastName are both required.

{
    "errors": [
        {
            "field": "AAA",
            "code": "44"
            "description": "Invalid/Missing Provider Name",
            "followupAction": "Please Correct and Resubmit",
                    "location": "Loop 2100D",
                    "possibleResolutions": "Provider's OrganizationName or LastName is required."
        }
    ]
}
  1. When you receive the following subscriber error, ensure the dateOfBirth field is formatted correctly. You may see more than one error for the related issue because the wrongly formatted date will also show up as an incorrect value against the payer database.
{
   "field": "subscriber.dateOfBirth",
   "description": "Invalid date format. 
                   Please use the following format:
                   yyyyMMdd."
}`
`{
   "field": "AAA",
   "code": "71",
   "description": "Patient Birth Date Does Not Match 
                   That for the Patient on the Database",
   "followupAction": "Please Correct and Resubmit",
   "location": "Loop 2100C"
   "possibleResolutions": "Patient Birth Date Does Not Match That for the Patient on the Database."
},
  1. The following is an error example for a request submitted with an error in the patientId. It is a fundamental issue that must be fixed before a query can be processed.
{
   "field": "patientId",
   "description": "Invalid/Missing Patient ID."
}
`{
    "errors": [
        {
            "field": "AAA",
            "code": "64"
            "description": "Invalid/Missing Patient ID"
            "followupAction": "Please Correct and Resubmit",
                    "location": "Loop 2100C"
                    "possibleResolutions": "Patient ID is incorrect in the request being sent."
        }
    ]
}`

📘

NOTE

See JSON-to-EDI API mapping for more information.

Eligibility API AAAErrors

Payers are considered the Information Source for all Eligibility queries, and this is the standard term in the medical industry. The provider submitting an eligibility query is called the Information Receiver

AAAErrors report on missing or invalid information from various parts of the submitted 270 Eligibility request and show possible resolutions. It is the standard error reporting system for all the Eligibility transactions. AAAErrors generate from seven different sections of eligibility queries.
Payer, Subscriber, Provider, and Dependent objects fall in the AAAError category.

AAAError Category

Description

Information Source level

Errors in this category indicate problems or mistakes in reaching the query's specified recipients, such as the Interchange/Clearinghouse ID (ISA06), or the payer (ISA08). The correct Interchange ID is important because the transaction you are submitting is used by both you, as the query sender and the ultimate receiver of the query, who is the payer that will verify the insurance coverage. There might be a mistake in the Payer object and the Interchange cannot locate it in the payer network.

Request Validation

Reports system errors, such as more patient queries than the submitter is allowed to send; the query is being sent by a provider that is not authorized to submit requests to the Payer; the Payer is experiencing network problems or otherwise unable to receive and process the submission, and other causes.

Information Receiver

Problems are detected in the request content defining the query sender — the Information Receiver of hoped-for insurance verification from the Payer. There is incorrect information in the Provider object, or possibly a missing PayerID.

Subscriber Request

There is incorrect content in the Subscriber object. A nicely detailed and extensive list of possible errors arises from this category. A significant one involves Invalid /Missing Subscriber/Insured Name, which usually denotes the patient in the request does not have active insurance with the Payer.
The Out of network messages are in this category.

Subscriber Request Validation

The request contains subscriber information that caused problems with processing it, such as incorrect dates, or in some cases the Payer requests more data.

Dependent Request

There is incorrect or missing content for the dependent in the Eligibility request. Many of the same error types you see for subscriber information also see usage here.

Dependent Request Validation

The request contains dependent information that caused problems with processing it, such as incorrect dates. In some cases the payer requests more data.

Eligibility AAAError Message Examples

  1. This error example is a Request validation error, showing code T4 describing that the request is missing correct payer information whether it is the correct payer name or the correct payorId. Because the submitter (the Information Receiver) has authorization to do business with the payer, the message Resubmission Allowed signals that the provider can fix the problem and try again.
{ 
    "field": "AAA", 
  "code": "T4", 
  "description": "Payer Name or Identifier Missing", 
  "followupAction": "Resubmission Allowed", 
  "location": "Loop 2100A",
  "possibleResolutions": "Payer Name or Identifier Missing."
},
  1. This error reports that the correct Provider information is missing in the request. It is an error from the Information Receiver Request Validation AAA category (Consult Page 243 of the ASC X12 Consolidated 270/271 Implementation Guide).
{
  "field": "AAA",
  "code": "43",
  "description": "Invalid/Missing Provider Identification",
  "followupAction": "Resubmission Not Allowed",
  "location": "Loop 2100D",
  "possibleResolutions": "Provider's NPI most likely is not registered with the payer, or not registered correctly with the payer, and the provider must contact payer directly to correct, Emdeon can not do this for them, it is a PHI/HIPPA restriction"
},
{
  "field": "AAA",
  "code" : "04",
  "description": "Authorized Quantity Exceeded",
  "followupAction": "Please Correct and Resubmit",
 }
{
   "field": "AAA",
   "code": "35",
   "description": "Out of Network",
   "followupAction": "Do Not Resubmit; Inquiry Initiated to a Third Party",
   "location": "Loop 2100C",
   "possibleResolutions": "Provider is not in network provider for the subscriber's plan"
},
{
  "field": "AAA",
  "code": "42",
  "description": "Unable to Respond at Current Time",
  "followupAction": "Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly",
  "location": "Loop 2100C",
  "possibleResolutions": "Is what we call the catch-all error.First place to start is look at PIRs to see if payer is having issues processing. If no PIR for payer call Command Center and have them check the system see if they are seeing trouble with the payer.Follow standard troubleshooting flow if no issue happening with payer."
},
{
  "field": "AAA",
  "code": "45",
  "description": "Invalid/Missing Provider Specialty",
  "followupAction": "Please Wait 30 Days and Resubmit",
  "location": "Loop 2100D",
  "possibleResolutions": "Provider's NPI not registered with the payer under the correct Specialty. Provider must contact payer directly to remedy this issue, due to PHI/HIPPA."
},
{
  "field": "AAA",
  "code": "47",
  "description": "Invalid/Missing Provider State",
  "followupAction": "Please Correct and Resubmit",
  "location": "Loop 2100D",
  "possibleResolutions": "Provider's address doesn't match what is listed with the payer or the NPPES system. Provider must contact payer directly to remedy this issue, due to PHI/HIPPA."
},
{
  "field": "AAA",
  "code": "48",
  "description": "Invalid/Missing Referring Provider Identification Number",
  "followupAction": "Do Not Resubmit; Inquiry Initiated to a Third Party",
  "location": "Loop 2100D",
  "possibleResolutions": "Referrals only: Referring provider's NPI is either not registered with the payer, provider must contact payer directly, or Enrollment with Emdeon is incorrect, contact enrollment department."
},
{
  "field": "AAA",
  "code": "49",
  "description": "Provider is Not Primary Care Physician",
  "followupAction": "Resubmission Not Allowed",
  "location": "Loop 2100D",
  "possibleResolutions": "Referrals only: Referring provider must be Primary Care Physician in some payer plans, insured must contact payer and set PCP in their system. Emdeon can not do this due to PHI/HIPPA guidelines."
},
{
  "field": "AAA",
  "code": "51",
  "description": "Provider Not on File",
  "followupAction": "Please Correct and Resubmit",
  "location": "Loop 2100C",
  "possibleResolutions": "Provider is not registered with the payer, provider must call payer directly to register their NPI"
}
{
  "field": "AAA",
  "code": "52",
  "description": "Service Dates Not Within Provider Plan Enrollment",
  "followupAction": "Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly",
  "location": "Loop 2100D",
  "possibleResolutions": "Provider was not registered in the insured's plan with the payer, on the DOS listed in transaction."
},
{
  "field": "AAA",
  "code": "57",
  "description": "Invalid/Missing Date(s) of Service",
  "followupAction": "Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly",
  "location": "Loop 2100D",
  "possibleResolutions": "DOS is not within allowable time frame, or DOS is missing in the 270"
}
{
  "field": "AAA",
  "code": "63",
  "description": "Date of Service in Future",
  "followupAction": "Please Wait 30 Days and Resubmit",
  "location": "Loop 2100C",
  "possibleResolutions": "Some Payers do not accept DOS in the future check payer instruction tables for specs per payer."
},
{
  "field": "AAA",
  "code": "72",
  "description": "Invalid/Missing Subscriber/Insured ID",
  "followupAction": "Please Correct and Resubmit",
  "location": "Loop 2100C",
  "possibleResolutions": "Subscriber member ID is incorrect in the request being sent."
},
{
  "field": "AAA",
  "code": "76",
  "description": "Duplicate Subscriber/Insured ID Number",
  "followupAction": "Resubmission Not Allowed",
  "location": "Loop 2100C",
  "possibleResolutions": "Duplicate member ID is found in the payer database."
},

AAAError Codes and Possible Resolutions

AAAError Code

Reason

Possible Resolution

04

Authorized Quantity Exceeded

Batches cannot contain more than 99 single transactions.

15

Required application data missing

Required missing/invalid data.

33

Input Errors

Check the input values.

35

Out of Network

Provider is not and in network provider for the subscriber's plan.

41

Authorization/Access Restrictions

  • If it comes before the 2000A Loop, it is most likely an enrollment issue with the vendor or provider's TID.
  • If it comes after the 2000A or after the 2000B Loop, it is an enrollment issue.
  • 42

    Unable to Respond at Current Time

    Known as the catch all error.

  • Look at PIRs to see if the payer is having issues processing
  • If there is no PIR for payer call Command Center, and have them check the the system to see if they are seeing trouble with the payer
  • Follow standard the troubleshooting flow if no issue shows with payer.

    43

    Invalid/Missing Provider Identification

    Provider's NPI most likely is not registered with the payer, or not registered correctly with the payer, and the provider must contact payer directly to correct, Emdeon can not do this for them it is a PHI/HIPPA restriction.

    44

    Invalid/Missing Provider Name

    Provider's NPI is registered with the incorrect name at the payer. Provider must contact the payer directly to have this issue fixed, due to PHI/HIPPA.

    45

    Invalid/Missing Provider Specialty

    Provider's NPI not registered with the payer under the correct Specialty. Provider must contact payer directly to remedy this issue, due to PHI/HIPPA.

    46

    Invalid/Missing Provider Phone Number

    Provider's phone does not match what is registered with the payer or the NPPES system for this provider. Provider must contact payer directly to remedy this issue, due to PHI/HIPPA.

    47

    Invalid/Missing Provider State

    Provider's address does not match what is listed with the payer or the NPPES system. Provider must contact payer directly to remedy this issue, due to PHI/HIPPA.

    48

    Invalid/Missing Referring Provider Identification Number

    Referrals only: Referring provider's NPI is either not registered with the payer, provider must contact payer directly, or Enrollment with Emdeon is incorrect, contact enrollment department.

    49

    Provider is Not Primary Care Physician

    Referrals only: Referring provider must be Primary Care Physician in some payer plans, insured must contact payer and set PCP in their system. Emdeon cannot do this due to PHI/HIPPA guidelines.

    50

    Provider Ineligible for Inquiries

    Provider is not registered for that service type with the payer, provider's has to contact payer directly.

    51

    Provider Not on File

    Provider is not registered with the payer, provider must call payer directly to register their NPI.

    52

    Service Dates Not Within Provider Plan Enrollment

    Provider was not registered in the insured's plan with the payer, on the Date-of-Service (DOS) listed in transaction.

    53

    Inquired Benefit Inconsistent with Provider Type

    Provider submitting a transaction for specialty that they are not registered with the payer to perform.

    54

    Inappropriate Product/Service ID Qualifier

    Provide an appropriate qualifier code/service ID and retry.

    55

    Inappropriate Product/Service ID

    Provide an appropriate service ID and retry.

    56

    Inappropriate Date

    Correct the date format and retry.

    57

    Invalid/Missing DOS

    DOS is not within the allowable time frame, or DOS is missing in 270/271.

    58

    Invalid/Missing Date-of-Birth (DOB)

    DOB is not included in 270/271 or DOB is incorrect in 270/271.

    59

    Invalid/Missing Date of Death

    Insured date shows has died and the DOD is either incorrect or missing from the transaction.

    60

    Date of Birth Follows Date(s) of Service

    DOS is before the DOB is, in which case the transaction would need to be submitted with the Mothers information.

    61

    Date of Death Precedes Date(s) of Service

    Insured date shows died before DOS listed in the transaction, provider must correct and resubmit.

    62

    DOS Not Within Allowable Inquiry Period

    DOS is outside of the accepted time frame for for requests to be submitted for the payer.

    63

    DOS in the future

    Some Payers do not accept DOS in the future check payer instruction tables for specs per payer.

    64

    Invalid/Missing Patient ID

    Patient ID is either missing and required by payer, or the Patient ID is incorrect in the request and needs to verified with a copy of insurance card.

    65

    Invalid/Missing Patient Name

    Patient name in request is either missing or is spelled differently in the payer database than what the provider entered into the request.

    66

    Invalid/Missing Patient Gender Code

    Request it missing the gender type code or patient or it is wrong.

    67

    Patient Not Found

    Patient is not in the payer's database or Patient is not included in the Data File used for Hosting.

    68

    Duplicate Patient ID Number

    There is either a different patient with the same member ID in the payer's database or in the Hosted Data File.

    69

    Inconsistent with Patient's Age

    When Diagnoses codes are inconsistent for patient's age.

    70

    Inconsistent with Patient's Gender

    Procedure codes are inconsistent with patient's gender.

    71

    Patient Birth Date Does Not Match That for the Patient on the Database

    DOB sent in request does not match what is in the payer's database, the subscriber will need to contact the payer to have this changed.

    72

    Invalid/Missing Subscriber/Insured ID

    Subscriber member ID is incorrect in the request being sent.

    73

    Invalid/Missing Subscriber/Insured Name

    Subscriber's name was submitted incorrectly, or the subscribers name is missing, or it is spelled incorrectly, in the request.

    74

    Invalid/Missing Subscriber/Insured Gender Code

    Subscriber's Gender code was not submitting, or is an invalid character, or it is wrong, as submitted in the request.

    75

    Subscriber/Insured Not Found

    Subscriber was not found for a direct connect payer, or is not included in the data file for hosted payers.

    76

    Duplicate Subscriber/Insured ID Number

    Duplicate member ID is found in the payer database.

    77

    Subscriber Found: Patient Not Found

    Subscriber was found in payer's database but the dependent's information is not in the payer's database.

    78

    Subscriber/Insured Not in Group/Plan Identified

    For Coventry payers, where request is sent to the incorrect payer plan database and the correct Group/Plan is listed in 271 in the LS2120 segment.

    79

    Invalid Participant Identification

    NPI in the request is not on file with the payer.

    80

    No Response received - Transaction Terminated

    Transaction timed out, check RT Tool to see if the payer is processing normally, if not processing normally, call the Command Center and have them check.

    AF

    Invalid/Missing Diagnoses Code(s)

    Provide the correct diagnoses code and retry.

    AG

    Invalid/Missing Procedure Code(s)

    Provide the correct procedure code and retry.

    IA

    Invalid Authorization Number Format

    Provide correct authorization number and retry.

    MA

    Missing Authorization Number

    Provide the authorization number and retry.

    T4

    Payer Name or Identifier Missing

    Correct the payer name/ID and retry.

    999 Errors

    In the event of a 999 error, the error.code will be set to the 999 and the following information is mapped.

    Segment

    Element

    Field

    IK

    301

    error.field

    Segment: %s

    IK

    302

    error.location

    the segment

    Loop: %s, Segment Position: %s

    IK

    303

    error.location

    the loop

    Loop: %s, Segment Position: %s

    IK

    304

    error.description

    IK

    40101-103,402,403,404

    error.followupAction

    Element Position in Segment: %s, Component Data Element Position in Composite: %s, Repeating Data Element Position: %s, Data Element Reference Number: %s, Implementation Data Element Syntax Error: %s, Copy of Bad Data Element: %s

    IK

    501

    response.transactionSetAcknowledgement

    IK

    502

    response.implementationTransactionSetSyntaxError


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