How To Interpret 997 Rejections

Now that we've covered the basic fundamentals of the 997 Functional Acknowledgment, we can start working on any errors or rejections contained in the 997.

Remember that we're reviewing a 997 transaction in response to an 837 EDI transaction that was submitted. Once we interpret the 997, we should have an idea of what the issue was in the originating 837 transaction.

Let's start with the first example.

Sample 997 - Accepted with Errors

  • ISA*00*          *00*          *ZZ*NEBLUECONNECT  *ZZ*SUBNUM         *100111*1523*U*00401*000000001*0*P*:~
  • GS*FA*NEBLUECONNECT*SUBNUM*20100111*152355*1*X*004010~
  • ST*997*0004~
  • AK1*HC*507243~
  • AK2*837*12218734~
  • AK3*CLM*51*2300*1~
  • AK5*E~
  • AK9*A*1*1*1~
  • SE*7*0004~
  • GE*1*1~
  • IEA*1*000000001~

The above 997 was accepted but with errors. How do we know that? By reviewing the codes contained in the AK501 and AK901 data elements. We've highlighted them in white for your reference.

The AK501 contains an 'E' which corresponds to "Accepted But Errors Were Noted"

The AK901 contains an 'A' which corresponds to "Accepted".

In this example, that's about all the AK5 and AK9 tell us about the issue so far. If there was additional information, there would be more data elements present in these segments.

We need to review the other segments contained in the 997 to figure the where and why. The AK1 and AK2 segments are used to help figure out which 837 transaction failed. The AK3 and AK4 segments are used to help figure out what data was incorrect in the 837 transaction.

For this article, we're only going to focus on the AK3 and AK4 segments. In our example above, there is only one AK3 segment.

  • AK3*CLM*51*2300*1~

In order to read the segment details provided, we need to have some basic information about the segment. Listed below you'll find information on the AK3 segment to help us.

AK3 - Data Segment Note

SegmentFieldNameDefinition
AK301Segment ID CodeIdentifies the data segment ID in error, for example REF.
AK302Segment Position in Transaction SetThe count position of the data segment in error, starting from the transaction set (ST).
AK303Loop Identifier CodeIdentifies the bounded loop, surrounded by the related LS and LE segments.
AK304Segment Syntax Error CodeCode indicating the error found in the data segment. See list here

Here are the fields and the data contained in those fields.

  • AK3 - AK3
  • AK301 - CLM
  • AK302 - 51
  • AK303 - 2300
  • AK304 - 1

What does this tell us? There was an error in the CLM segment contained in the 2300 Loop, at numerical position 51 with an error code of 1. The 1 stands for "Unrecognized segment ID", found on the following table

AK304 - Segment Syntax Error Code

CodeDefinition
1Unrecognized segment ID
2Unexpected segment
3Mandatory segment missing
4Loop Occurs Over Maximum Times
5Segment Exceeds Maximum Use
6Segment Not in Defined Transaction Set
7Segment Not in Proper Sequence
8Segment Has Data Element Errors

Unfortunately, this doesn't tell us exactly what the problem was. The next step is to take this information and go look at the 837 transaction to see if you can tell. If you can't figure it out, contact the trading partner you sent the transaction to. They should be able to pinpoint the cause.

Let's do another example.

Sample 997 - Rejected with Errors

  • ISA*00*          *00*          *ZZ*NEBLUECONNECT  *ZZ*SUBNUM         *100111*1523*U*00401*000000001*0*P*:~
  • GS*FA*NEBLUECONNECT*SUBNUM*20100111*152355*1*X*004010~
  • ST*997*0008~
  • AK1*HC*508243~
  • AK2*837*12218734~
  • AK3*NM1*84*2310A*8~
  • AK4*9*67*7*1245990011~
  • AK5*R~
  • AK9*R*1*1*1~
  • SE*8*0008~
  • GE*1*1~
  • IEA*1*000000001~

We know that this 997 rejected with errors because of the values in the AK5 and AK9 segments. Remember that 'R' is rejected. We can move straight to the AK3 and AK4 segments.

  • AK3*NM1*84*2310A*8~

Here are the fields and the data contained in those fields.

  • AK3 - AK3
  • AK301 - NM1
  • AK302 - 84
  • AK303 - 2310A
  • AK304 - 8

What does this tell us? There was an error in the NM1 segment contained in the 2310A Loop, at numerical position 84 with an error code of 8. The 8 stands for "Segment Has Data Element Errors". See the table above for more values.

This 997 rejection also included an AK4 segment, which we haven't discussed yet.

  • AK4*9*67*7*1245990011~

In order to read the segment details provided, we need to have some basic information about the segment. Listed below you'll find information on the AK4 segment to help us.

AK4 - Data Element Note

SegmentFieldNameDefinition
AK401Position In SegmentCode identifying the position of the data element or composite data structure in error. The count starts with 1.
AK401-1Element Position in SegmentIdentifies the position of the data element or composite data structure in error.
AK401-2Component Data Element Position in CompositeIdentifies the position of the data element within the composite data structure in error.
AK402Data Element Reference NumberIdentifies the data element reference number of the data element in error. For example, the data element REF01 has a data element reference number of 128.
AK403Data Element Syntax Error CodeCode indicating the error found in the data element. See list here
AK404Copy of Bad Data ElementContains a copy of the identified data element in error. Not used if the error was an invalid character.

Here are the fields and the data contained in those fields.

  • AK4 - AK4
  • AK401 - 9
  • AK402 - 67
  • AK403 - 7
  • AK404 - 1245990011

What does this tell us? There was an error at reference number 67 and element position 9, which corresponds to the NM109 data element. The syntax error code of 7 means "Invalid code value". The actual data that had the error was 1245990011.

AK403 - Data Element Syntax Error Code

CodeDefinition
1Mandatory data element missing
2Conditional required data element missing.
3Too many data elements.
4Data element too short.
5Data element too long.
6Invalid character in data element.
7Invalid code value.
8Invalid Date
9Invalid Time
10Exclusion Condition Violated

Let's put it all together. After analyzing the AK3 and AK4 segments we can conclude that the error happened in the 2310A loop at data element NM109. The bad data was 1245990011.

The 2310A loop is also known as the Referring Provider Loop. The NM109 is where the referring Provider NPI number goes. So, either 1245990011 is an invalid NPI number or the trading partner kicked it out because the NPI is valid but not in their payer system.

The final piece of the puzzle is matching up the 997 with the corresponding 837 transaction. Continue reading the next article where we discuss matching 997 acknowledgment with the 837 transaction.