Affinity Health Plan EDI Claim Status Codes and Emdeon Clearinghouse Claim Status Codes
Affinity Health Plan EDI Claim information, unique to Affinity Health Plan claims, must be provided and properly formatted in the EDI file. Affinity Health Plan EDI Claim sent to Emdeon is checked at the clearinghouse for format and syntax errors. If Emdeon identifies an error, the Affinity Health Plan EDI Claim is rejected by Emdeon and is NOT sent to Affinity. Emdeon will provide sender with a claim status report, listing the error reason for each rejected claim.
If an EDI claim passes the Emdeon clearinghouse edits, it is then forwarded to Affinity. When Affinity receives an 837 EDI claim file from the Emdeon clearinghouse, the claims are checked again for errors. If Affinity identifies errors in an EDI claim, that claim is rejected by Affinity and claim status information is sent to the Emdeon clearinghouse. Emdeon, in turn, will provide sender with a claim status report, identifying claims rejected by Affinity. Below are the current claim status codes used by Affinity/Emdeon.
|Affinity Code||Reason Code Description Sent to Emdeon||Emdeon Claim Status Message Sent to Provider|
|20||Claim accepted||Carrier Acknowledges Receipt Of Claim|
|QF7||Claim rejected – Provider Not Found||Billing Provider Tax ID/EIN Missing/Invalid NPI|
|BF||Claim rejected – Member Not Found||Subscriber/Member ID Not Found|
|30||Claim Pending||Claim Is Pending at Receiver Site|
|40||Claim Adjudication Process Completed||Claim Adjudication Process Has Been Completed By Carrier|
|PB||Under Final Processing-No Action Required At This Time||Under Final Processing-No Action Required At This Time|
|CDV||Medicare Claims with DOS on or after 1/1/2010 should be submitted to Payer 13333||Medicare Claims with DOS on or after 1/1/2010 should be submitted to Payer 13333|
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