How to Avoid a 496 Edit

Since the HIPAA 5010 electronic claims standards took effect in January, some practices are running into a problem that causes TrailBlazer Health Enterprises to send back their Medicare claims with a 496 edit (submitter not approved for electronic claim submissions on behalf of this entity). TrailBlazer says this happens because the practice either is not properly linked to a clearinghouse or vendor in the Medicare system or has made an error in the claim.

TrailBlazer has some advice on how to avoid problems:

Do not assume that because you were properly linked to a clearinghouse or vendor under the old 4010 system that you still are under the 5010 standards. The claim forms for each format differ, and some linkages were made nearly a decade ago. In addition, TrailBlazer says large clearinghouses that have been repeatedly bought, sold, and combined now use new submitter numbers. The 5010 format automatically screens for valid linkages and stops invalid submitter IDs, reporting a 496 edit. When this happens, you need to contact your clearinghouse or vendor. 

The 496 edit also can occur if a practice:

  • Submits a claim using a rendering physician's (the physician who actually treated the patient) National Provider Identifier (NPI) instead of the billing physician's NPI, or
  • Bills Part B services for a physician associated with a group under his or her individual NPI when it should be billed under the group NPI.

Call the TrailBlazer support line at (866) 749-4302 if you have further questions or need technical help. 

Action, March 1, 2012