Generating an ERA if Required Data is Missing or Invalid

40.2 - Generating an ERA if Required Data is Missing or Invalid (Rev. 2843, Issued: 12-27-13, Effective: 01-28-14, Implementation: 01-28-14) The ASC X12 835 IG contains specific data requirements, which must be met to build a HIPAA compliant ERA. A claim could be received on paper that lacks data or has data that does not meet the data attributes or length requirements for preparation of a HIPAA- compliant ERA. If not rejected as a result of standard or IG level editing, a MAC must either send an SPR advice or a “gap filled” ERA to avoid noncompliance with HIPAA. For example, if a procedure code is sent with only four characters and the code set specified in the IG includes five character codes in the data element, and the code is not rejected by the front end edits, the claim would be denied due to the invalid procedure code. Preparation of an ERA with too few characters though would not comply with the IG requirements. The noncompliant ERA could be rejected by the receiver. The shared system maintainers, working in conjunction with their MACs, must decide whether to generate an SPR, which is not covered by HIPAA, or to “gap fill” in this situation, depending on system capability and cost. Except in some very rare situations, “gap filling” would be expected to be the preferred solution. Shared System Maintainers must follow CMS gap-filling instruction. The MAC must notify the trading partners, if and when their files are affected, as to when and why gap-filling characters will appear in an ASC X12 835.