Affinity Health Plan

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  • Claim Status Codes

    Emdeon Claim Status Codes

    When Emdeon receives electronic claims from you, each claim is checked at the clearinghouse for format and syntax errors. If Emdeon identifies an error, the claim is rejected by Emdeon and is NOT sent to Affinity. Emdeon will provide you with a claim status report, listing the error reason for each rejected claim. Click here for the complete list of Emdeon Claim Status Codes.

    Affinity Claim Status Codes

    If an EDI claim passes the Emdeon clearinghouse edits, it is then forwarded to Affinity. When Affinity receives an 837 claim file from the Emdeon clearinghouse, the claims are checked again for errors. If Affinity identifies errors in a claim, that claim is rejected by Affinity and claim status information is sent to the Emdeon clearinghouse. Emdeon, in turn, will provide you 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
    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

    If you are not contracted with Affinity Health Plan and you receive a claim rejection code of “QF7”, please click on the Verification Form link listed to the left.

    If your practice is contracted with Affinity and you receive a claim rejection code of “QF7”, please click on the NPI Update link listed to the left. If you have already provided NPI data to Affinity Health Plan, please email Provider Relations at: provider@affinityplan.org.