Rejected Medicare Claims May Have a Linkage Problem

With the implementation of the HIPAA 5010 standard for submitting electronic claims, some practices are running into a “linkage problem” with Medicare claims, which results in rejected claims.

This error will appear on your 277 Claims Acknowledgement as a 496 edit (submitter not approved for electronic claim submissions on behalf of this entity) in the message “A8:496:85.” TrailBlazer Health Enterprises says this edit can result from one of two types of errors, which you can correct on your end.

Clearinghouse/Vendor Submitter Linkage

You cannot assume a successful provider and clearinghouse/vendor submitter linkage in 4010 means you should be successfully linked in 5010; the claim forms for each format differ, and some linkages initially were made nearly a decade ago. In addition, TrailBlazer reports that 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 for bad linkage.  When this happens, you need to contact your clearinghouse/vendor about resolving the problem.

NPI Billing Errors

The 496 edit also can occur If you:

  • Submit a claim using a rendering physician’s National Provided Identifier (NPI) instead of the billing physician NPI (the rendering physician is not associated with the clearinghouse/vendor submitter), or
  • Bill 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.

If you have further questions, or need technical help, call the TrailBlazer support line at (866) 749-4302. More information about 5010 is available in the TMA HIPAA 5010 Resource Center.

Published Feb. 28, 2012

TMA Practice E-Tips main page

Last Updated On

November 11, 2013

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