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EDI Claim EditsUnitedHealthcare applies Health Insurance Portability and Accountability Act (HIPAA) edits for professional(837P) and institutional (837I) claims submitted electronically. Enhancements to these edits may occurperiodically, affecting most payer IDs on the Claims Payer List for UnitedHealthcare, Affiliates and StrategicAlliances; exceptions are Harvard Pilgrim (04271) and The Alliance (88461). WEDI SNIP types 1 through 6are applied at a pre-adjudication level during HIPAA validation for the following edits:WEDI SNIPEdit DescriptionClaim TypeType Claredi EDINumberNumber1H10005Value is too short for 'NM109'XX1H10006Value is too longXX1H10012Data contains invalid character(s) from neither the basic, nor theextended character setXX1H10014Leading zeros detected in CTP04; The X12 syntax requires thesuppression of leading zeros for numeric elementsXX1H10016Leading spaces are not allowed (N401)XX1H10017Non-alpha-numeric or -space character (.) is not allowed here(N403)XX1H10018Trailing spaces are not allowed (N402)XX1H10046Syntax error: NM108 was found but NM109 was missing; X12 syntaxrule: 'P0809' - if one element is present, all must be presentXX1H10049Syntax error: No listed element was found. X12 syntax rule: 'R0203' at least one element must be presentXX1H10611Excess Trailing Data Element Delimiter(s)XX1H10614Missing Mandatory 'HI1002'XX1H10904Number of Included Segments '306' does not match actual segmentcount '305'XX1H11202Incomplete InterchangeXX1H11203Transaction Set Trailer missingXX1H11204Code Value ' ' not used for element 'PWK02'XX1H11205Incomplete Functional GroupXX1H11402HL segment marked as having children but in fact has noneXX1H11615Segment terminator detected in element contentsX1H11617Interchange Control Number (ISA13) must be unique within a fileXX1H12034Element repetition separator found in non-repeating elementXX2H20067DTP03 ' ' has bad date specification; Wrong length - should be'CCYYMMDD'XX2H20070HH portion of time field must be 00-23XX2H20203Code Value 'N' at element 'CLM09' is valid in the X12 standard but notin this HIPAA implementationXX2H20204Code Value at element 'CLM09' is valid in the X12 standard but not inthis HIPAA implementationXX2H20205Incomplete loop (2310E); Missing HIPAA-required N4 (Ambulance Pickup Location City, State, ZIP Code)XX2H20600Value does not match the format for a Federal Tax IdentificationNumberXX2H20601Value does not match the format for a National Association of InsuranceCommissioners CodeXX2H20612Value 'CO18' does not match the format for a MOA Remark CodeXX2H20617Value does not match the format for a 'HIPAA National Provider ID(NPI)'XX837P 2021 UnitedHealthcare Services, Inc.Page 1 of 6Comments837I07/19/2021
WEDI SNIPEdit DescriptionClaim TypeType Claredi EDINumberNumber2H20618Value '.' does not match the format for a Person's name - must be atleast one letterXX2H20622Value does not match the format for a UPINXX2H20624Value does not match the format for an ICD9 Diagnosis Code (digits, E,V codes only)XX2H20628Value does not match the format for a NUBC Revenue Code. Revenuecodes must be 4 digits, usually including a leading zeroXX2H20631Blank value supplied for data elementXX2H20658Segment REF exceeded HIPAA max use countXX2H20751Invalid ZIP CodeXX2H20753Invalid Canadian Postal CodeXX2H20759NDC Code value is too long; Must be a 5-4-2 formatted code withoutthe hyphens (11 digits only)XX2H20760NDC Code value is too short; Must be a 5-4-2 formatted code withoutthe hyphens (11 digits only)XX2H20761ICD9 Codes should not contain periods2H20801MOA Remark Codes must not leave gaps in the segmentX2H20802'Diagnosis Code' composites must not leave gaps in themX2H20904Suppress edit if Claim Adjustment Reason Code 237 is duplicatedXX2H23038Decimal data elements in Data Element 782 (Monetary Amount) will belimited to a maximum length of 10 characters including 2 reported orimplied places for centsXX2H23041Not a valid date - day does not fall in month in this yearXX2H24215State or Province was not found, but was expected because the RelatedCauses Code (CLM-11-1) is ‘AA-Auto Accident’X2H24235Group Name was found but was not expected because the GroupNumber (SBR03) is present2H24236'Claim Filing Indicator Code' was not found but was expected becausePlanID has not yet been mandated2H24274'Health Care Code Information' was not expected because the OtherDiagnosis Industry Code (HI-04-2) is not presentX2H24276'Health Care Code Information' was not expected because the OtherDiagnosis Industry Code (HI-06-2) is not presentX2H24365'Procedure Modifier' was not expected because the HCPCS Modifier 1(SV2-02-3) is not presentX2H24391Missing HIPAA Required 'xxx'XX2H24402Value fails the check digit algorithm for the HIPAA National Provider ID(NPI)XX2H24410Subscriber ID cannot be used in the NM1 segment because theSubscriber is not a PersonXX2H25367Country Code was found but not expected because the country is theUnited States (N404 US)XX2H25370Telephone/FAX number in PER must be exactly 10 positions long - thevalue '9999820' is too shortXX2H25371Telephone/FAX number in PER must be exactly 10 positions long - thevalue is too longXX2H25375Billing Provider Address must be a street address; Post Office Box orLock Box addresses are to be sent in the Pay-to-Provider AddressXXXXXXX837P'Billing Provider Postal Zone or ZIP Code' must be the nine digit Zipcode'Billing Provider Postal Zone or ZIP Code' must be the nine digit ZipcodeXXH253762H253772H25387'Billing Provider Tax Identification Number' does not match the formatof a Tax ID NumberX2H25388Service Facility Contact Name was found but was not expected becauseit is the same as Submitter Loop (1000A) or the Billing Provider Loop(2010AA)XPage 2 of 6XX2 2021 UnitedHealthcare Services, Inc.Comments837IX07/19/2021
WEDI SNIPEdit DescriptionClaim TypeType Claredi EDINumberNumber2H25389Code 'ER - Jurisdiction Specific Procedure and Supply Codes' is not validfor HIPAA at the time of the writing of the implementation guideX2H25390Payer Claim Control Number' was not found but was expected becausethe 'Claim Submission Reason Code' (CLM05-3) is 7 or 8XX2H25392Line Item Control Number must be unique within a claimXX2H25393Zip Code is required when the address is in the US or CanadaXX2H25405Point of Origin for Admission or Visit is required for all inpatient andoutpatient services except for Type of Bill '14X'X2H25407Admitting Diagnosis must be used because this claim is for InpatientServicesX2H25584Group or Policy Number (2000B SBR03) and (2320 SBR03) cannot be'NONE', 'None' or 'none'2H25602Admitting Diagnosis was found but not expected because this claim isfor outpatient servicesX2H25620Classification of either inpatient or outpatient could not be determinedsince the Bill Type is invalidX2H25643A second iteration of the Condition Information segment is not allowedunless all twelve data elements in the first iteration are present.2H25651If ICD10 Diagnosis Codes are submitted, any procedure codessubmitted must be ICD10 Procedure CodesX2H25652If ICD9 Diagnosis Codes are submitted, any procedure codes submittedmust be ICD9 Procedure CodesX2H25653If ICD10 and ICD9 Diagnosis Codes cannot be sent on the same claimplease split the claim before resubmittingX2H25655Adjustment Reason Amount cannot be zero (2320 and 2430)XX2H25656Duplicate condition codes not allowed on a claimXX2H25659Gaps not allowed between Patient Reason for Visit codesX2H25660Gaps not allowed between External Cause of Injury codes (2300 HI03through HI12)X2H25670Duplicate Diagnosis Pointers are not allowed2H25671Duplicate Treatment Codes are not allowed for Patient Reason for VisitCodes3ALL 4H40038Ambulance Transport Information is required on all ambulancetransport servicesX4H40101Subscriber address required if the Subscriber is the patientXX4H40102Subscriber City/State/Zip required if the Subscriber is the patientXX4H40103'Individual Relationship Code' (SBR-02) must be '18-Self' when'Hierarchical Child Code' HL-04 0 for 'No Subordinate HL Segment'XX4H40106When the Subscriber is the Patient, the 'Relationship Code' in SBR-02must be '18-Self'XX4H40131'Bundled/Unbundled Line Number' must be less than or equal to theLine Counter (2400/LX-01) for Loop 24004H40142Discharge Date (DTP-01 096) was not expected because this claim isnot for Inpatient ServicesX4H40160'Form Identification Code' indicates a DMERC CMN form but none wasfound in 2400/PWK-02X4H40163Admission Date (2300-DTP01 435) required on inpatient claimsX4H40164Admission Date (2300-DTP01 435) not allowed on outpatient claimsX4H40165Admission Date (2300-DTP01 435, DTP02 DT) required on inpatientclaimsX4H40176'Acute Manifestation Date' is required on Medicare claims when thePatient Condition Code in CR2-08 is 'A'837P Page 3 of 6XXXXXExcept H31312 2021 UnitedHealthcare Services, Inc.XComments837IXXX07/19/2021
WEDI SNIPEdit DescriptionClaim TypeType Claredi EDINumberNumber4H40192When a 'Diagnosis Code Pointer' is '2', a 'Diagnosis Code' in 2300/HI-022 must existX4H40193When a 'Diagnosis Code Pointer' is '3', a 'Diagnosis Code' in 2300/HI-032 must existX4H40195When a 'Diagnosis Code Pointer' is '5', a 'Diagnosis Code' in 2300/HI-052 must existX4H40197When a 'Diagnosis Code Pointer' is '7', a 'Diagnosis Code' in 2300/HI-072 must existX4H40358'Acute Manifestation Date' cannot be used unless the Patient ConditionCode in CR2-08 is 'A' or 'M'X4H40365'Discharge Hour' (2300 DTP-01 096) was not found but was expectedbecause the Claim Frequency Code (CLM-05-3) is '1 - Original' or '4 Last Claim' and this claim is for Inpatient Services.4H41110Undefined 'Other Payer ID Number' - this pointer must point to anexisting 'Other Payer ID Number' in Loop 2330BX4H41202Patient Amount Paid of '0' is not an acceptable valueX4H42003‘EPSDT Referral Condition Certification Indicator’ (CRC02) of ‘N’ isrequired if the ‘Condition Indicator’ (CRC03) is ‘NU-Not Used’X4H45114Subscriber State Code was not found but was expected because theSubscriber Relationship (SBR-02) is '18-Self'X4H45117'Payer City/State/ZIP Code' was not found but was expected becausethe Payer Address Line (N3) is presentX4H45125'Claim information' was not expected because the SubscriberRelationship (SBR-02) is not 18-SelfX4H45150'Coordination of Benefits (COB) Payer Paid Amount' was not found butwas expected because the Other Subscriber Claim Adjustment segment(2320/CAS) is presentX4H45153'Other Subscriber City/State/ZIP Code' was not found but was expectedbecause the Other Insured Address Line (N3-01) is presentX4H45173'Admission Type Code' was not found but was expected because thisClaim is for Inpatient Hospital servicesX4H45175'Other Procedure Information' was not expected because the PrincipalProcedure Information is not presentX4H45185'Medicare Inpatient Adjudication Information' was not expected becausethis Claim is for Outpatient servicesX4H45202'Date - Accident' was not found but was expected because the RelatedCauses Code (CLM-11-1) is present and is not 'EM-Employment'X4H45215'Composite Diagnosis Code Pointer' was not found but was expectedbecause the Principal Diagnosis Code (HI01-1) is presentX4H45216'Composite Diagnosis Code Pointer' was not found but was expectedbecause the Diagnosis Code (HI021) is presentX4H45217'Composite Diagnosis Code Pointer' was not found, but was expectedbecause the Diagnosis Code (HI031) is presentX4H45218'Composite Diagnosis Code Pointer' was not found but was expectedbecause the Diagnosis Code (HI041) is presentX4H45219'Composite Diagnosis Code Pointer' was not found but was expectedbecause the Diagnosis Code (HI051) is presentX4H45225'Purchased Service Provider Name' was not expected because thePurchased Service Provider Identifier (PS1-01) is not presentX4H45227'Purchased Service Provider Name' was not expected because thePurchased Service Provider Identifier (PS1-01) is not presentX4H45228'Purchased Service Provider Name' was not found, but was expectedbecause the Purchased Service Provider Identifier (PS1-01) is presentand the Claim Level Purchased Service Provider is not presentX4H45233'Ordering Provider City/State/ZIP Code' was not found but was expectedbecause the Ordering Provider Address Line (N3-01) is presentX837P 2021 UnitedHealthcare Services, Inc.Page 4 of 6Comments837IXXXX07/19/2021
WEDI SNIP*Edit DescriptionClaim TypeType Claredi EDINumberNumber4H45238'Form Identification Code' was not expected because the AttachmentTransmission Code (PWK-02) is 'AB-Previously Submitted to Payer'X4H45245'Ordering Provider City, State, ZIP Code' (2420E N4) was not found butwas expected because the DMERC CMN (2400 PWK) is presentX4H45255Other Subscriber Primary Identifier (2330A NM109) cannot be the sameas the Group or Policy Number (2320 SBR03)X4H45318Subscriber City, State, ZIP Code was not expected because theSubscriber Relationship (SBR-02) is not 18-SelfX4H46001'Billing Provider UPIN/License Information' not expected because theNPI was sent as the primary identifierX4H46215Service Facility Location is not used when reporting ambulance servicesX4H46216Other Insurance Group Name must not be used if the Group Number issubmittedXX4H46218Payer Paid Amount or any CAS segments are not allowed when the COBTotal Non-Covered Amount is submittedXX4H46219COB Total Non-Covered Amount must equal the Total Claim ChargeAmount (CLM02)XX4H46226'Invalid 'Diagnosis Code Pointer' - must be 1 through 12 inclusiveX4H46227When a 'Diagnosis Code Pointer' is '9', a 'Diagnosis Code' in 2300/HI-092 must existX4H46228When a 'Diagnosis Code Pointer' is '10', a 'Diagnosis Code' in 2300/HI102 must existX4H46229When a 'Diagnosis Code Pointer' is '11', a 'Diagnosis Code' in 2300/HI112 must existX4H46211The Attachment Control Number should not be sent if PWK02 AAX4H46251Service Date is required on outpatient services when a drug is not beingbilled and the Statement Covers Period is greater than one dayX4H46255Other Operating Provider was found but was not expected because theOperating Provider was not submittedX4H46283Subscriber Group or Policy Number was found but was not expectedbecause it is the same as the valuesent as the Subscriber Primary IDX4H46447Ambulance Pick-Up and Drop-Off Locations are required for ambulanceclaimsX4H46474Other Subscriber Information was not found but was expected becausethe destination payer is not the primary payerXX4H46500COB Payer Paid Amount was expected because the claim has beenadjudicated by the payer identified in Other Payer LoopXX4H46504'Service Line Date' was not expected because this Claim is for InpatientservicesX4H46506Attending Provider (2310A) is required on all bills except unscheduledtransportation claimsX4H46542Payer Claim Control Number not allowed on original claimsX4H46544EPSDT Referral Information must be present when a screening serviceis billedX4H46551Duplicate Occurance Span Codes not allowed on a claimX4H46548Occurance Code 55 requires a Patient Status Code of 20, 40, 41, 94, or42X5ALL 6H61161837P Except H50010, H51090, H51123Patient Reason for Visit loop must be included if the 2300 CLM05-1 isequal to facility code 13, 85 or 78Comments837IXeffective7/8/2021XXXXXX WEDI SNIP Transaction Compliance Types 1-6Type 1 - EDI Syntax IntegrityType 2 - HIPAA Implementation Guide Requirements 2021 UnitedHealthcare Services, Inc.Page 5 of 607/19/2021
WEDI SNIPType Claredi EDINumberNumberEdit DescriptionClaim Type837PComments837IType 3 - HIPAA BalancingType 4 - HIPAA Inter-Segment SituationType 5 - HIPAA External Code SetType 6 - Product Type and Type of Service* Change or additionDeletions by effective date:6/5/2014 H462484/25/2014 H465203/7/2014 H46235, H46236, H46240, H46246, H46252, H46253, H46473, H511319/24/2015 B25099, B25140, B25144, B25150, B25155, B251541/13/2016 H465469/1/2016 Medica HealthCare Plans (78857) and Preferred Care Partners (65088) no longer exceptions8/7/2019 H46203 2021 UnitedHealthcare Services, Inc.Page 6 of 607/19/2021
Billing Provider Address must be a street address; Post Office Box or Lock Box addresses are to be sent in the Pay-to-Provider Address: X X: 2 H25376 'Billing Provider Postal Zone or ZIP Code' must be the nine digit Zip code X X: 2 H25377 'Billing Provider Postal Zone or ZIP Code' must be the nine digit Zip code X X: 2 H25387
