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ERROR 026: PROVIDER IS NOT VALID FOR THIS SUBMITTER

Rejection Message Rejection Details Resolution

ERROR 026: PROVIDER IS NOT VALID FOR THIS SUBMITTER

 

There are three possible reasons why the claim is rejecting for this reason:

  1. The practice is not credentialed with this payer.
  2. Claims are being sent out with the incorrect billing information.
  3. Claims are being submitted to the wrong payer ID.

Submitter Action:
Please contact the payer’s EDI department for the following information:

  1. Verify the Provider IDs the payer has on file to determine what information the claimed should be billed under.
    1. Is the Provider enrolled with their Group NPI or Individual NPI?
    2. Is the Provider enrolled with their Tax ID or SSN?
  2. Verify if there are any additional payer-assigned Provider IDs that also need to be submitted on the claims. If so, what loop and segment should the information be populated in?
  3. Verify the Payer ID used is correct/valid for the policy information submitted.

The resolution instructions below correspond with the numbered “reasons” to the left:

  1. If the practice is not credentialed with the payer, please contact the payer for further assistance.
  2. If the claim was sent with different billing information than what is on file with the payer, follow the instructions below to update the billing information for a specific provider and specific insurance company:
    1. Click Settings > Providers.
    2. Look for and open the provider record.
    3. Click on the Claim Settings tab.
    4. Click Add.
    5. Click Insurance Company.
    6. Look for and select the insurance company.
    7. Change the NPI dropdown to the appropriate option (depending on how you bill).
    8. (If necessary) Check “Override NPI” if a different Group NPI or Individual NPI needs to be entered.
    9. Change the Tax ID dropdown to the correct option (depending on how you bill).
    10. (If necessary) Check “Override EIN” if a different tax ID needs to be entered.
    11. Click Save all the way out (multiple saves may be required).
    12. Then, rebill and resubmit all affected claims.
  3. If the claims are being submitted to the wrong payer ID, follow the instructions below to edit the payer ID associated with the claim:

Note: Changes made within the Edit Insurance Plan or Edit Insurance Company pages will apply to ALL insurance policies and claims tied to that Insurance Plan or Company within the practice.

The payer ID can be updated in two ways:

  1. By changing the payer ID associated with this insurance company:
    1. Click Encounters > Track Claim Status.
    2. Look for and double-click on the encounter that needs correcting.
    3. Double-click on the Case.
    4. Double-click on the appropriate Insurance Policy.
    5. Double-click on the Insurance Plan name to open the Edit Insurance Plan page.
    6. Double-click on the Insurance Company name to open the Edit Insurance Company page.
    7. Click the Electronic Claims tab. The current payer ID is listed in the Clearinghouse Payer ID field.
    8. Click the Electronic Payer Connection button.
    9. Search for and select the correct payer ID for the claim.
    10. Click Save all the way out (multiple saves may be required).
  2. By associating the insurance policy with another insurance company (with the correct payer ID):
    1. Click Encounters > Track Claim Status.
    2. Look for and double-click on the encounter that needs correcting.
    3. Double-click on the Case.
    4. Double-click on the appropriate Insurance Policy.
    5. Click the Insurance button.
    6. Look for an Insurance Plan with the correct payer ID (listed under the “EDI Payer Number” column).
      • If there are no insurance plans associated with the correct payer ID a new insurance plan and insurance company will need to be created.
    7. Double-click on the appropriate insurance plan to associate it with the patient’s insurance policy.
    8. Verify all other information listed on the policy is correct.
    9. Click Save all the way out (multiple saves may be required).

Then, rebill and resubmit all affected claims.

Note: Please verify enrollment is completed (or not needed) before submitting e-claims to a new Payer ID.

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